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
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
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
Children with developmental differences are disproportionally represented in the foster care system
Fragile X syndrome is the most common INHERITED disorder of intellectual disability
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
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