Elisabeth Pollio, PhD

CARES Institute

Rowan University School of Osteopathic Medicine

September 20, 2013

Developmental delays ◦ especially language delays, cognitive problems,

and gross motor difficulties

Behavior problems ◦ aggression, oppositionality, attentional difficulties

High-risk behavior ◦ cutting, substance use, risky sex, impulsivity

Emotional problems ◦ anxiety, posttraumatic stress, depression, suicidal

thoughts and attempts

School problems ◦ academic failure, dropping out

Later delinquent behavior

Study defined ACE categories as abuse and household dysfunction

As number of childhood exposures increased, the prevalence and risk increased for: ◦ Depressed mood, Suicide attempts ◦ Alcoholism, Drug use, Smoking ◦ Obesity, Physical inactivity ◦ Heart disease, Cancer, Lung disease, Liver disease

Children in foster care often have a history of these adverse childhood experiences

Psychological Evaluation ◦ Clarify diagnoses, treatment recommendations

Psychiatric Evaluation ◦ Clarify diagnoses, assess need for medication

Specialized Sexual Abuse Evaluation ◦ Clarify allegations of sexual abuse, recommend services

Neuropsychological Evaluation ◦ Assess cognitive & executive functioning difficulties,

recommend interventions

CHEC Exam ◦ Mental health screening & medical evaluation for children

entering foster care, recommend services

Issue-Specific Evaluations (fire setting, psychosexual, substance use) ◦ Assess current risk for behavior, treatment

recommendations

Often helpful to read entire report (unless very technical)

Summary and recommendations for “bottom line”

Five-Axis Diagnosis (DSM-IV) ◦ Axis I : Primary Disorder ◦ Axis II : Personality Disorder/Mental Retardation ◦ Axis III : Medical Condition ◦ Axis IV : Stressors ◦ Axis V : Global Assessment of Functioning (GAF)

Early Intervention (EI) Services ◦ Complete developmental assessments for

children up to age three

◦ To determine services needed for helping children catch up developmentally

Child Study Team (CST) Evaluation ◦ Ages three and older

◦ To determine eligibility for special education services

Posttraumatic Stress Disorder (PTSD)

Major Depressive Disorder (MDD)

Oppositional Defiant Disorder (ODD)

Attention-Deficit/Hyperactivity Disorder (ADHD)

Autism Spectrum Disorders (ASD)

Conduct Disorder

Bipolar Disorder

Reactive Attachment Disorder

Exposure to a traumatic event involving actual or threatened:

◦ Death, injury, or sexual violence through: Direct exposure Witnessing Indirectly (learning about) Repeated or extreme indirect exposure (professionals)

Intrusion (Re-experiencing) ◦ Recurrent, intrusive memories (in children, can be

repetitive play)

◦ Traumatic nightmares (in children, content is not necessarily about the trauma)

◦ Flashbacks

◦ Intense or prolonged distress when exposed to trauma reminders

◦ Physical reactions when exposed to trauma reminders

Avoidance ◦ Avoidance of trauma-related thoughts or

feelings ◦ Avoidance of trauma-related external

reminders (people, places, activities, etc.)

Alterations in Arousal/Reactivity ◦ Irritable or aggressive behavior ◦ Self-destructive or reckless behavior ◦ Hypervigilance ◦ Exaggerated startle response ◦ Concentration difficulties ◦ Sleep disturbance

Negative Alterations in Cognitions and Mood (new in DSM-5) ◦ Inability to recall key features of event

◦ Negative beliefs about self and world

◦ Distorted blame of self or others

◦ Negative trauma-related emotions

◦ Diminished interest in activities

◦ Feeling detached from others

◦ Constricted affect

Depressed mood ◦ in children/adolescents, irritable mood

Loss of interest or pleasure in things previously enjoyed

Sleep and/or appetite disturbance

Restlessness

Decreased energy

Poor concentration

Feelings of worthlessness, hopelessness, or thoughts of death

Physical complaints in children

A pattern of negative, hostile, and defiant behavior toward authority ◦ Often loses temper

◦ Often argues with adults

◦ Refuses to comply with adult requests

◦ Often angry or resentful/spiteful or vindictive

◦ Deliberately annoys people

◦ Blames others for mistakes

◦ Easily annoyed

Inattention ◦ Makes careless errors

◦ Difficulty sustaining attention

◦ Not follow through on instructions

◦ Easily distracted

◦ Forgetfulness

◦ Loses things

Hyperactivity ◦ Fidgets

◦ Runs excessively

◦ Trouble playing quietly

◦ Talks too much

Impulsivity ◦ Trouble awaiting turn

◦ Interrupts others

◦ Blurts out answers before questions are completed

Role of child/adolescent psychiatrist

Importance of follow-up

Issues with multiple medications and antipsychotics

Modality ◦ Individual, Group, Family

Type of Therapy -General vs. Trauma-focused

-In-home vs. Out-of-home therapy

Evidence-Based Treatment ◦ TF-CBT with children in foster care

◦ decrease in placement disruptions and running away

Provide information to therapist

Provide support to child

Coach child through use of skills

Critical for treating behavior difficulties

Metropolitan Regional Diagnostic & Treatment Center

Newark Beth Israel Medical Center at Wynona’s House

185 Washington Street Newark, NJ 07102 (973) 753-1110

Audrey Hepburn Children's House

Joseph M. Sanzari Children's Hospital Hackensack University Medical Center

30 Prospect Avenue Hackensack, NJ 07601

(201) 996-2271

Dorothy B. Hersh Regional Child Protection Center Children's Hospital at St. Peter's University Hospital 123 How Lane New Brunswick, NJ 08901 (732) 448-1000

CARES Institute

Rowan University School of Osteopathic Medicine

42 East Laurel Road

Stratford, NJ 08084

(856) 566-7036

Dr. Barbara E. Cohen M.D. FAAP

CARES Institute

Rowan University School of Osteopathic Medicine

September 20, 2013

Failure to thrive Growth Faltering

Medical

Developmental

Social

Societal/legal

A BMI below the 5th % is considered abnormal unless the child has always been below the 5th % and is growing along the curve.

Weight and/or length below the 5th percentile

This an excellent example of a worrisome growth chart. You can see that something changed at 6 months of age. The baby is further below the 5th % at 12 months than he was at 6 months when the

faltering began.

WHO standard references for children 0 – 24 months

CDC growth charts for children 2 – 18 years

Specialized growth charts for babies born prematurely

Specialized growth charts for children with Down syndrome and some of the other genetic syndromes

Gastrointestinal reflux

Upper GI obstruction

Pyloric stenosis

Malabsorption

Lactose intolerance

Cystic fibrosis

Inborn error of metabolism

Inflammatory bowel disease

Problem with breastfeeding

Lack of formula

Improper formula preparation

Caregiver depression

Infant feeding disability

Uncoordinated suck and swallow

Congenital abnormality of

the mouth or palate

Economic hardship

Eating disorder

Thyroid disease

Chronic infection (HIV)

Chronic lung disease

Congenital heart disease

Malignancy

FAS FETAL ALCOHOL SYNDROME Gin Lane

A print by the artist Hogarth from 1751

Judges 13:7

813 BC Ancient Carthage

384-322 Aristotle

1725: College of Physicians in London

1899: Dr. William Sullivan in Liverpool

1. Growth abnormalities

2. Evidence of CNS damage

3. FAS Facial Phenotype

4. Gestational alcohol exposure

SGA infant

Microcephaly

Problems with brain formation

Behavioral problems

Intellectual disability

Children with developmental differences are disproportionally represented in the foster care system

Fragile X syndrome is the most common INHERITED disorder of intellectual disability

Healthy Brain Fragile X Brain

ANY child with an intellectual disability, learning disability, speech and language delay, or autism

Long face

Prominent forehead

Prominent lower jaw

Protruding ears

Macro-orchidism in adolescent males

High-arched palate

Connective tissue disorder

Poor eye contact

Hand biting

Hand flapping

Poor attention

Anxiety

Social avoidance

United States: 1/110 8 year olds

New Jersey: 1/94 8 year olds

1. Presence of repetitive stereotyped behavior

2. Difficulty with social skills

3. Difficulty with language/communication

Level 1 screening test: designed to identify children at risk for autism within the general population

23 item parent questionnaire with a scripted interview for failed items.

The test has been referenced on over 16,000 children.

When administered with the follow-up interview, the M-CHAT has a sensitivity of 87-97% and a specificity of 95-99%.

Available free on the internet (www. mchatscreen.com or www.firstsigns.org)) in multiple languages

6 Critical Questions

1. Does your child take an interest in other children?

2. Does your child ever use their index finger to point to ask for something?

3. Does your child ever bring objects over to show you?

4. Does your child imitate you?

5. Does what your child respond to their name when you call?

6. If you point at a toy across the room, will your child look at it?

If a child fails the M-CHAT screening test, the standard of care is a referral to a diagnostic center

In NJ, there exist 6 clinical centers established through the Governors Council on Autism

In addition, there are other schools and medical centers, and private practitioners that provide assessments

Center for Neurological and Neurodevelopmental Health (Gibbsboro)

A new patient will be scheduled to see the neurologist within 3 weeks

If the neurologist decides the patient needs further testing, an appointment with be scheduled with a neuropsychologist for an Autism Diagnostic Observation Schedule, the current gold standard for diagnosis. As of October, they were scheduling into January.

The Hunterdon Regional Autism Center

Flemington, NJ

They are booking for next month but they only see children from Hunterdon, Somerset, Warren, Mercer, Morris and Middlesex counties

The Institute for Child Development Hackensack

Hackensack, NJ

In October, they were scheduling for January

K. Hovanian Children’s Hospital at Jersey Shore University Medical Center

Scheduling 3-4 months out

The Children’s Specialized Hospital – Tom’s River

Rutgers Medical School -Newark

Children’s Hospital of Philadelphia

Children under the age of 3 years are seen within 6 months

Children between 3 and 13 years are seen within a year

Cooper University Pediatric Autism Program

There is a 3 month wait to see a child neurologist

Nemours/Dupont: 1 year wait for an appointment

Dr James Coplan: He is located in Ardmore, PA and can schedule new patients in 2 weeks. He does not accept any insurance .

Center for Family Guidance: Located in Marlton; 1 – 2 months for an appointment; no insurance accepted

A complete list of diagnostic resources can be down-loaded from the Autism New Jersey website