Journal of Developmental and Behavioral Pediatrics最新文献

Background: Children in the foster care system often have a host of prenatal and postnatal risk factors that can compromise development including disruptions in important attachment relationships. We argue that to effectively address this complex history and inform specific recommendations for intervention, it is important for an Early Childhood Mental Health (ECMH) evaluation to include both an assessment of the caregiver-child relationship status and neurodevelopment.

Case presentation: We describe an ECMH evaluation for a 21-month-old girl who was referred to a multidisciplinary birth to three specialty clinic for difficulties separating from her preadoptive mother, indiscriminate friendliness, and emotional and behavioral dysregulation. She had a history of prenatal substance exposure and several disruptions in important attachment relationships. We gained insight into the caregiver-child relationship through behavioral observations and used standardized testing to assess neurodevelopment. This combination of assessment techniques revealed inconsistencies in secure base attachment patterns between the parent and child. She also performed lower than what would be expected for her age across several domains of development.

Conclusion: This case highlights a comprehensive approach to an ECMH evaluation. Recommendations for intervention prioritized the parent-child relationship given the importance of attunement between caregiver and child to first optimize stress regulation and thus set the foundation for higher-order cognitive processes to develop.

Case: Juan is a 5-year-old boy who has been followed by a developmental-behavioral pediatrician and pediatric neuropsychologist since being diagnosed with language delay and autism spectrum disorder at age 2 years. He is otherwise healthy and was born at term after a healthy pregnancy. His primary language is Spanish, and he has minimal interactions in English. His first words were at 20 months; they were not functional but rather words related to his interests such as "train." He began using 2 to 3-word phrases shortly after but only to request needs. He began speaking in complete sentences at age 4 years.A neuropsychological evaluation was conducted at age 2 years during which Juan demonstrated repetitive behaviors such as hand-flapping, toe-walking, body rocking, and head banging. He displayed sensory seeking behaviors such as rubbing items on his face and close visual inspection. He did not respond to his name and his use of eye contact was inconsistent. He demonstrated rigidity and difficulty transitioning between activities. He did not engage in social reciprocity, and his facial expressions were limited. Minimal spontaneous language was observed, and expressive language largely consisted of echolalia in both languages. Juan was diagnosed with autism spectrum disorder and applied behavior analysis, speech and language therapy, and occupational therapy were recommended.Developmental-behavioral follow-up over the next 2 years noted improvements in behavior, transitions, and social interactions. He participated in early childhood intervention and early childhood special education with significant advances for speech and language in English and Spanish, demonstrating a large vocabulary. At 4 years, parents noted Juan to have reluctance to speak in English. He stopped speaking in English entirely for 3 weeks, though he continued to speak in Spanish. When he resumed speaking in English, it was only with people he knew well (e.g., parents, teachers, babysitter). In clinic, he did not speak to the English-speaking developmental-behavioral pediatrician but spoke in short sentences to the Spanish-speaking neuropsychologist.A repeat neuropsychological evaluation completed at age 5 years revealed that Juan had stopped speaking in English completely, even among those previously deemed "safe." Results were consistent with average cognitive abilities with a strength in verbal skills. Juan's single-word vocabulary in Spanish was exceptionally high. He did not provide expressive responses in English, but his receptive English vocabulary was high average. He responded to English language with nonverbal gestures or spoken language in Spanish. Parents reported Juan to display increased anxiety accompanied by extreme school refusal, behavioral difficulties, and reluctance to leave the home.Given this information, what are your diagnostic considerations and treatment recommendations?

Objective: Despite automatic eligibility, many children with medical conditions associated with increased risk of disability do not receive Early Intervention (EI) services. State EI programs have compiled lists of established conditions to facilitate automatic enrollment; yet little is known about professionals' knowledge and utilization of these lists. This study examined the knowledge of these established conditions lists and associated policies and procedures among pediatricians and EI personnel. State initiatives and approaches undertaken to improve familiarity and utilization of the list, along with recommendations for its improvement were examined.

Method: In this mixed-methods study, self-rated survey data were collected from 193 EI personnel responsible for intake and eligibility evaluations, and 69 pediatricians providing primary care. Follow-up interviews were then conducted with 45 EI personnel and 22 pediatricians. Quantitative data were analyzed using descriptive statistics, and qualitative data underwent thematic analysis.

Results: Pediatricians rated their knowledge of their state's established conditions list and related policies and procedures lower than EI personnel. Both groups emphasized the significance of the list in referral and eligibility determination but highlighted its underutilization and lack of professional development activities. Consequently, recommendations were made to improve state established conditions lists and their utilization in ensuring direct EI enrollment for eligible children.

Conclusion: The lack of shared knowledge and utilization of established conditions lists and associated policies and procedures among pediatricians and EI personnel may result in referral failure for eligible children. Addressing this challenge requires improvement in the content and statewide distribution to improve accessibility and usability.

Abstract: Executive function (EF) development is vital for children and adolescents, with physical activity (PA) playing a key role in its enhancement. Through a systematic review and multilevel meta-analysis, this study investigates the effectiveness of cognitively engaging physical activity (CEPA) over traditional PA in fostering EF in children and adolescents. The research involved 1671 participants across 15 studies to determine if CEPA is superior to PA in enhancing EF and to analyze interventions and dose-response effects. Results demonstrated that CEPA had a more pronounced impact on EF development compared with PA, with a Hedges' g of 0.50 (95% confidence interval, 0.10-0.48), although potentially overestimated due to small-study effects and publication bias. Subgroup analyses did not find notable differences in effectiveness among various intervention types. The most substantial effect was observed with 45-minute interventions, while frequencies less than twice weekly and durations beyond 12 weeks were less effective. These findings suggest that CEPA could be a more efficacious method for advancing EF in youth, indicating a need for larger-scale randomized controlled trial (RCTs) to confirm the results and more accurately estimate their magnitude.

Background: Congenital heart disease (CHD) is a risk factor for developmental delay and for attention-deficit hyperactivity disorder (ADHD). The Cardiac Neurodevelopmental Outcome Collaborative has developed recommendations for ongoing monitoring of this at-risk population to be able to detect developmental, learning, and behavioral concerns, as they become apparent as a child ages.

Case presentation: A 4-year-old boy with tetralogy of Fallot with a ventricular septal defect repaired in infancy was followed periodically in the cardiac neurodevelopmental follow-up clinic and diagnosed with autism spectrum disorder as well as additional developmental and medical issues. He received early childhood special education and therapeutic interventions as well as social skills training and applied behavior analysis. At age 4 years, Alex presented with symptoms of hyperactivity, inattention, impulsivity, and immediate safety concerns for elopement. The clinician diagnosed him with ADHD-combined type. He was recommended to start medication in addition to behavioral and developmental supports. Managing medications in a child with CHD and ADHD presents unique challenges, and medication decisions were carefully made in collaboration with the child's cardiologist. After some medication adjustments and ongoing behavioral therapy to address behaviors associated with ADHD and autism spectrum disorder, the child is doing well academically and socially.

Conclusion: Attention-deficit hyperactivity disorder medications can be safely prescribed in patients with CHD. However, pharmacotherapy for co-occurring ADHD and CHD needs an additional level of oversight and collaboration between cardiology and prescribing clinicians. Behavioral therapies can be transdiagnostic and address challenges associated with autism and symptoms related to ADHD.

Objective: The aim of this study is to identify characteristics of children for whom a developmental-behavioral pediatrician's (DBP) diagnostic impressions of autism spectrum disorder (ASD) or non-ASD were changed by Autism Diagnostic Observation Schedule (ADOS) results.

Method: A prospective study of children 1½ to <6 years consecutively referred to 8 sites for possible ASD. Cognitive/developmental, language, and adaptive testing varied, as each site followed its usual clinical approach. DBPs documented diagnosis as ASD or non-ASD and their degree of diagnostic certainty (1-10) pre- and post-ADOS. Cases where DBP diagnostic impression did not change after ADOS administration ("Stable Group," n = 314) were compared with those for whom it did change ("Changed Group," n = 35), followed by matched random sample comparisons.

Results: There were no significant differences in child characteristics (age, gender, race, ethnicity, insurance, caregiver education) between the Stable and Changed groups. DBPs' diagnostic certainty was significantly lower, both pre- and post-ADOS, in the Changed versus Stable group. Change was associated with milder symptoms of ASD and less impaired language. In an age- and gender-matched comparison, significant differences remained for diagnostic certainty and severity of social communication impairments. Cognitive scores were significantly higher in the Changed Group. Because of significantly higher caregiver education and a trend toward more privately insured children among the Changed Group, samples (n = 35 each) were then matched on those characteristics, revealing the same differences for diagnostic certainty, severity of ASD symptoms, and language skills.

Conclusion: Young children with milder ASD symptoms and less impaired language may benefit most from the administration of the ADOS.

Objective: Suboptimal sleep is associated with disruptive behaviors in childhood. We evaluate associations of mean and variability (SD) of sleep duration, quality, and timing with emotion regulation, impulsivity, and prosocial and antisocial behavior in children.

Methods: Intervention Nurses Start Infants Growing on Healthy Trajectories, a randomized controlled trial designed for obesity prevention, compared a responsive parenting intervention delivered in the first 2.5 years after birth with a home safety control group. At age 6 years, children wore an actigraphy device for 7 days and participated in behavioral tasks evaluating behavioral control, emotion regulation, and prosocial and antisocial behaviors. Separate linear regression models examined associations between sleep and behavioral variables, adjusting for study group, child sex, and household income. Moderation analysis investigated whether the study group moderated relationships between sleep and positive age-appropriate behavior.

Results: Children (N = 143, age 6.7 ± 0.3 years) were predominantly non-Hispanic White (95%). Mean actigraphic sleep duration, quality, and timing were not associated with behavioral variables. By contrast, greater variability in sleep onset timing was associated with greater impulsivity (B = 0.85, p = 0.004) and poorer emotion regulation (B = -0.65, p = 0.01). Greater variability in sleep midpoint timing was associated with greater impulsivity (B = 0.80, p = 0.03). The study group moderated the effect of sleep onset variability on behavior; only the home safety control group exhibited a significant negative relationship between variability in sleep onset timing and emotion regulation (B = -1.28, p = 0.0002).

Conclusion: Findings support the importance of consistency in sleep timing and how this may play a greater role in children's behavioral and emotional outcomes than mean actigraphic sleep duration and quality.

Objective: Adolescents with problematic internet use (PIU) have excessive, impulsive, or risky internet use that negatively affects social, physical, and functional outcomes. The role of parents in the prevention of adolescent PIU remains unclear. The purpose of this study was to evaluate possible association between adolescent PIU, parent PIU, and internet-related parenting factors.

Methods: Adolescents aged 12 to 18 years and a parent were recruited through national Qualtrics panels for an online cross-sectional survey. Adolescents and parents completed the Problematic and Risky Internet Use Screening Scale-3 (PRIUSS-3) and Internet-Specific Parenting Practices (ISPP) scales for (1) internet content (ISPP-content) and (2) time on the internet (ISPP-time). Adolescents completed ISPP for quality of parent communication regarding internet use (ISPP-Quality). Bivariate analyses examined relationships between adolescent PIU, parent PIU, and ISPP.

Results: In total, 4558 adolescents and 4568 parents completed surveys. Adolescent PIU prevalence was 69.9%. Parent PIU prevalence was 61.4%. Among parents with PIU, 87% had an adolescent with PIU compared with only 42% of parents without PIU (OR = 9.54, 95% CI: 8.24-11.05). More lenient content parenting practices and stricter time parenting practices were associated with increased likelihood of adolescent PIU. The quality of parent communication around the internet was lower for adolescents with PIU.

Conclusion: Study findings suggest that coaching around positive parent-child relationships and healthy family internet use habits that include shared digital experiences may more effectively address PIU than enforcing child screen time limits.

Case: Leo is a 28-month-old boy from a monolingual Spanish-speaking family who was referred to a developmental-behavioral pediatrics (DBP) clinic for concerns regarding autism. His parents migrated to the United States 8 years ago and currently live and work on a farm. He was born in a US hospital after an uncomplicated pregnancy and has been generally healthy. His parents first became concerned about his development when he was 16 months old. He stopped saying mama/dada in Spanish and started lining up random objects. He had frequent temper tantrums and was difficult to console during unexpected changes in his routine. He screened positive on the Modified Checklist for Autism in Toddlers, Revised with Follow-Up (M-CHAT-R/F) at his 18-month well-child visit, and his pediatrician referred him to the local early intervention program. Calls from the early intervention program to his parents were unanswered. At his 24-month well-child visit, he again screened positive on the M-CHAT-R/F, and his pediatrician placed a referral for a DBP consultation. During the DBP visit at 28 months of age, developmental testing indicated his receptive and expressive language skills to be in the extremely low range, with significant scatter in his cognitive and adaptive skills. Behavioral observations were consistent with parental history and showed differences in social communication and interaction, the presence of repetitive behaviors, and extreme distress with transitions. He was diagnosed with autism spectrum disorder. Recommendations, including referral to early intervention, applied behavior analysis therapy, speech and language therapy, audiology evaluation, and genetic testing, were discussed with his parents through an interpreter. An autism packet, written in Spanish, with detailed information about autism and community resources was given to the family. By the time of a follow-up DBP visit 6 months later, Leo had not started on any early intervention or therapeutic services. Where do you go from here?

Objective: The objective of this study was to quantify associations of infant 24-hour sleep duration and nighttime sleep consolidation with later child cognition.

Methods: This study included children from Project Viva, a prospective cohort in Massachusetts with (1) sleep measures in infancy (median age 6.4 months) and (2) child cognition in early childhood (median age 3.2 years) or mid-childhood (median age 7.7 years). Main exposures were parental reports of infant 24-hour sleep duration and nighttime sleep consolidation (% of total daily sleep occurring at nighttime). Cognitive outcomes were (1) early childhood vocabulary and visual-motor abilities and (2) mid-childhood verbal and nonverbal intelligence quotient (IQ), memory, and visual-motor abilities. We examined associations of infant sleep with childhood cognition using linear regression models adjusted for child sex, age, and race or ethnicity; maternal age, education, and parity; and household income.

Results: Early and mid-childhood analyses included 1102 and 969 children, respectively. Most mothers reported infant race or ethnicity as White (69%) and were college graduates (71%). The mean infant 24-hour sleep duration was 12.2 ± 2.0 hours, and the mean nighttime sleep consolidation was 76.8% ± 8.8%. Infant 24-hour sleep duration was not associated with any early or mid-childhood outcomes. Higher infant nighttime sleep consolidation was associated with higher mid-childhood verbal intelligence (β: 0.12 points per % nighttime sleep; 95% CI, 0.01-0.22), but not with any early childhood cognitive measures.

Conclusion: In this cohort, higher infant nighttime sleep consolidation was associated with higher verbal IQ in mid-childhood. Future studies should investigate causal relationships of infant sleep consolidation with child cognition among diverse populations.