880 Peds Exam 2 (legal, CP, DS, ASD, DCD, ABI)

PA's definition of child abuse and neglect

when an individual acts or fails to prevent something that causes harm or a high likelihood of harm to a child <18

What is any non accidental physical injury to the child & can include striking, kicking, burning, or biting the child, or any action that results in a physical impairment of child?

physical abuse

What is failure of a parent or other person w/ responsibility for child to provide needed food, clothing, shelter, medical care, or supervision to degree that child's health, safety, & well-being are threatened w/ harm?

neglect

What is injury to psychological capacity or emotional stability of child as evidenced by an observable or substantial change in behavior, emotional response, or cognition" & injury as evidenced by "anxiety, depression, withdrawal, or aggressive behavior?

emotional abuse

What are factors associated w/ parental substance abuse (5)

-Prenatal exposure of a child to harm due to mother's use of an illegal drug or other substance
-Manufacture of a controlled substance in presence of a child or on premises occupied by a child
-Allowing a child to be present where chemicals or equipment for manufacture of controlled substances are used or stored
-Selling, distributing, or giving drugs or alcohol to a child
-Use of a controlled substance by a caregiver that impairs caregiver's ability to adequately care for child

What is when parent's identity or whereabouts are unknown, child has been left by parent in circumstances in which child suffers serious harm, or parent has failed to maintain contact w/ child or to provide reasonable support for a specified period of time?

abandonment

what are the PA laws regarding when child restraints are required for passenger safety (rear facing restraint, forward facing restraint, booster seat requirements)

< 2 y/o (or until outgrows top height or weight recommendations) require rear-facing child restraint
2-3 y/o in forward-facing child restraint
4-7 y/o requires booster seat

between what ages is the adult safety belt permissible in the state of PA regarding child passenger safety laws

8-18 years

What is a group of permanent disorders of development of mvmt & posture, causing activity limitation, that are attributed to nonprogressive disturbances that occurred in developing fetal or infant brain (brain lesion is STATIC) however it is accompanied by PROGRESSIVE 2ndary impairments?

cerebral palsy

list primary impairments of CP

-Spasticity
-Reduced postural control
-Reduced selective voluntary motor control
-Impaired sensory processing

list secondary impairments of CP

-Muscle or tendon contractures
-Skeletal Deformities
-Decreased strength (when spasticity is addressed)
-Limited endurance

What is the relationship between birth weight & prevalence of CP

Children w/ LBW (<3.3 lbs) have higher risk of developing CP (59.5 per 1,000 live births)

What is the relationship b/t gestation age at birth & prevalence of CP?

Infants born preterm (28-31 wks) have increased likelihood of developing CP (35-79.5 per 1,000 live births)

define APGAR

Appearance (skin color)

Pulse (HR)

Grimace response (reflexes)

Activity (muscle tone)

Respiration (breathing rate & effort)

describe the scoring of the APGAR

>7 is considered good health
if score is <7, medical team will continue to take a score every 5 mins until it reaches an acceptable lvl of death
APGAR score of < 3 at 5 mins of age is indicative of high probability of CNS deficits

what are the 4 ways CP can be classified

1. location of brain lesion
2. type of mvmt d/o (spastic, dystonic, ataxia, hypotonic)
3. extent & location of limb involvement (monoplegia-tetraplegia)
4. function (via GMFCS)

describe the 4 movement disorders used to help classify CP

1. Spastic Type: increased tone & stiff muscles

2. Dyskinetic Type: abnormal, uncontrollable mvmt patterns which may be slow & writhing or rapid & jerky (athetoid, choreoathetoid, & dystonic CP)

3. Ataxic Type: abnormal mvmt patterns, including poor balance & coordination

4. Hypotonic Type: low muscle tone, 10% of individuals w/ CP

define monoplegia, diplegia, hemiplegia, quadriplegia/tetraplegia

-Monoplegia: 1 extremity involved

-Diplegia: impairment of B LEs, sometimes UEs may also be involved, but to a much lesser extent than LEs

-Hemiplegia: impairment of UE/LE on same side of body

-Quadriplegia/ Tetraplegia: All extremities involved

what is the highest functioning level on GMFCS & what is the lowest functioning level on the GMFCS?

-Level 1: highest lvl of fnx, indicating least impairment

-Level 5: lowest lvl of fnx, indicating most severe impairment

define GMFCS level I

Walks w/o limitations & w/o AD at home, school, outdoors, & in community
-climbs stairs w/o use of HR
-performs gross motor skills (jump/run) but has decreased speed, balance, & coordination

define GMFCS level II

-walks in most settings w/ some limitations
-has difficulty walking long distances, balancing on uneven terrain/inclines/confined areas
-climbs stairs w/ use of HR
-minimal ability to run & jump
-may need HH mobility device when 1st learning to walk but are capable of walking w/o HH mobility after age 4
-may use wheeled mobility when traveling long distances

define GMFCS level III

-walks using HH mobility devices in most indoor settings (typ a reverse RW)
-may climb stairs w/ HR & SV or assistance
-uses wheeled mobility when traveling long distances (outdoors/comm) & may self-propel for shorter distances
-children 12-18 y/o level III may self-propel a manual WC indoors or use powered mobility outdoors
-able to sit on their own or require limited external support (at most)
-independent in standing transfers

What GMFCS lvl requires PA or powered mobility in most settings for mobility? (self mobility is limited)

-may walk for short distances at home w/ PA or use powered mobility or a body support walker when positioned

-transported in a manual WC or use powered mobility at school, outdoors, or in community

-function in sitting (usually supported)

GMFCS level IV

What GMFCS lvl must be transported in a manual WC in all settings?

-limited in their ability to maintain antigravity head & trunk postures & control leg & arm mvmts

-requires extensive assistive technology & PA

-self mobility is achieved only if child can learn how to operate a PWC

GMFCS level V

what are the intervention goals for GMFCS levels I-III

-Develop gross motor skills (standing, walking, running, jumping)
-Functionally oriented goals: may not follow typical developmental sequence
-Promotion & maintenance of msk integrity
-Prevention of 2ndary impairments
-Enhancement of functional postures & mvmt
-Maintenance of optimal lvls of fitness & overall health

what are the intervention goals for GMFCS levels IV-V

-Early continuous postural mgmt programs; use equipment as needed (sitting: 6 months of age, supported seating equipment; standing 12 months of age (wheeled mobility))
-Functionally oriented goals (may not follow typical developmental sequence)

What depicts how children w/ CP utilize their hands in daily activities?

-Ages 4-18

-Child's need for A to perform manual activities in school, leisure, & ADLs

-Levels 1-5 (1= least impaired; 5= most impaired)

Manual ability classification system (MACS)

define all 5 levels of the MACS

I: Handles objects easily & successfully
II: Handles most objects but w/ somewhat reduced quality &/or speed of achievement
III: Handles objects w/ difficulty; needs help to prepare &/or modify activities
IV: Handles a limited selection of easily managed objects in adapted situations
V: Does not handle objects & has severely limited ability to perform even simple actions

What depicts the communication abilities of children w/ CP?

-Based on typical performance in everyday situations

-Sender, receiver, pace of communication, degrees of familiarity w/ communication partner

-Considerations any mode of communication

-Levels 1-5 (1= least impaired, 5= most impaired)

Communication function classifications (CFCS)

define all 5 levels of the CFCS

1: Effective sender & receiver w/ unfamiliar & familiar partner
2: Effective but slower paced sender &/or receiver w/ unfamiliar &/or familiar partners
3: Effective sender & receiver w/ familiar partners
4: Inconsistent sender &/or receiver w/ familiar partners
5: Seldom a effective sender & receiver even w/ familiar partners.

What outcome measure is validated for children w/ CP & DS?

-Appropriate to use w/ individuals dx w/ CP or DS whose motor skills are at or below those of 5 y/o child w/o motor disability

GMFM-88

what are the dimensions of the GMFM

-Lying & Rolling
-Sitting & standing
-Crawling & Kneeling
-Walking, Running, & Jumping

The easiest item on GMFM is rolls to prone over R side. What is the hardest?

standing on a 6” step, jumps off w/ both feet simultaneously

describe the 4 point scoring system for the GMFM

0= does not initiate
1= initiates
2= partially completes
3= completes

what are the most important muscle groups to assess ROM in children w/ CP?

-Hip abduction (w/ knees flexed (adductor magnus, brevis, & longus; w/ knees extended (gracilis)

-Hip extension: Thomas test position (w/ knees extended (iliopsoas); w/ knees flexed (rectus femoris)

-Knee extension (w/ hip flexion (popliteal angle- hamstring)

Ankle Dorsiflexion (w/ knees flexed (soleus); knees extended (gastrocnemius))

how should you assess strength in a child w/ CP b/t 3-5 y/o?

-Assess in functional context
-Consider MMT for 4-5 y/o who are able to follow instructions of test

how should you assess strength in a child w/ CP b/t 6-21 y/o?

-MMT or hand held dynamometry
-Observe functional mvmts

what characteristics would a child w/ spastic CP present w/ when standing?

-PF (tip toes) w/ knee hyperextension
-hips ADD & IR
-pelvis in anterior tilt

What is a crouched standing posture sometimes seen in children w/ CP when assessing ROM?

tend to stand w/ ankle DF, knee flexion, & hips in ADD, flexion, & IR

what characteristics would a child w/ CP present w/ when sitting if they have decreased HS ROM?

knees in flexion & posterior pelvic tilt w/ compensatory lumbar & thoracic kyphosis & neck hyperextension

how is posture ability & posture in Posture & Postural Ability Scale (PPAS) scored?

-posture ability: assesses lvl of postural ability on a 7 point scale ranging from 1 (“unplaceable in an aligned posture”) to 7 (“able to move into & out of position”)

-Posture: assesses quality of posture in 4 positions, scoring 0-1 on 6 descriptors as observed from frontal view & 6 descriptors from sagittal view

-all motions assessed in supine, prone, sitting, standing

Scoliosis in CP results from: (5)

-Decreased stability
-Atypical postures
-Atypical muscle pull
-Muscle imbalances
-LLD (which leads to pelvis asymmetry)

what does hypertonicity typically result in w/ CP?

frequently results in hip flexion, ADD, IR posturing, & contractures

what are the pelvic abnormalities from in CP?

-Obliquity: due to LLD (typically functional LLD)
-Posterior pelvic tilt: due to limited HS ROM
-Anterior pelvic tilt: due to hip flexor tightness

why are hip subluxes/dislocations common in ppl w/ CP?

due to ↓ WB thru LE at early age due to delay in milestones → do not undergo typical bone remodeling allowing femur to sit in w/in acetabulum
-atypical muscular pulls/spasticity characterized by ↓ hip ABD ROM & hip flexion contractures causing hip instability

what are the critical ROM values for hip stability

at least 30° of ABD & avoiding hip flexion contracture of 20-25° or greater

What is the angular difference b/t axis of foot & line of progression (in-toeing, out-toeing) → long axis of foot is compared w/ direction in which child is walking?

foot progression angle

what would represent a positive angle & what would indicate a negative angle?

-If long axis of foot is directed outwardly, angle is (+)
-If foot is directed inwardly, angle is (-) & is indicative of in-toeing

What are the 4 motor control & balance characteristics associated w/ CP?

-Delayed reactive & anticipatory postural control & postural sway

-may lower their COG by flexing their knees, w/ feet in either excessive PF or DF

-Greater reliance on proximal musculature for balance (use hip & stepping strategies more than ankle strategies for balance)

-difficulty maintaining postural control in stationary postures

What is the jump-style gait?

Hip & knee flexion & PF in stance

What is crouched gait?

-Hip & knee flexion thru stance
-Gastroc insufficiency

What is Recurvatum gait?

Knee hyperextension mid to late stance

define stiff gait

Decreased flexion in swing

When assessing spasticity in children w/ CP use the Tardieu's R1 & R2 method:

R1= point of 1st catch tested w/ fast velocity (dynamic endpoint dependent on pt position) → take ROM at catch point
R2= if you take them into a LLLD stretch→ will gain ROM (equivalent to PROM, full range when muscle is at rest & tested w/ velocity as slow as possible)

what do timing errors in muscle recruitment result in?

-delayed initiation of mvmt
↓ RFD
-prolonged muscle contraction
-disrupted timing of agonist & antagonist activation
-difficulty dissociating individual limb or joint mvmt

What is the MobQues28 (who can fill it out & who is it used for, what is the rating scale, what the 28 tasks include)

-parent-report questionnaire used for children ages 4-13 w/ CP who are able to walk (GMFCS I-III)
-rates child's level of difficulty w/ 28 mobility tasks on a 5-point scale from "impossible w/o help" to "not difficult at all"
-includes mobility on level surfaces, uneven surfaces/over changes in elevation, transitioning b/t positions, & recreational activities

why is LLLD more effective than manual stretching when treating spasticity?

Maintaining current muscle length requires muscles to be in an elongated state for 6 hrs or more per day

what is the most common cause of both death & acquired disability in childhood?

TBI

define primary damage of TBI

injury that occurs as a result of forces at initial impact

what are the 3 primary causes of TBI

-accel/deccel (transitional or rotational forces/shear force causing DAI likely via MVA)
-crush injury (frontal or temporal areas due to low velocity impact via fall/blow to head)
-penetration (related to fall on nails, pencils, or sharp sticks causing focal damage)

What is an injury/damage that occurs as a result of processes that are initiated in response to initial trauma?

2ndary damage of TBI

what are the 2 categories of secondary brain damage

-intracranial causes (brain hemorrhage & brain swelling)
-extracranial causes (hypoexima & hypotension)

what GCS scores are considered to be indicative of a mild TBI, mod TBI, and severe TBI

-Mild TBI = GCS of 13-15
-Mod TBI = GCS if 9-12
-Severe TBI = GCS of 3-8

what are the coma durations associated with mild TBI, mod TBI, severe TBI, & very severe TBI

-Mild = coma lasting < 20 mins
-Mod = coma lasting 20 min-6 hrs
-Severe = coma lasting 6-24 hrs
-Very severe = coma lasting >24 hrs

What is the classification & cause of near drowning injuries leading to ABI?

-classified as a hypoxic injury caused by tissue O2 deficiency
-near drowning, inhalation of a foreign body hanging & strangulation, suffocation, apnea

what are poor outcomes of near drowning injuries associated with

-prolonged cardiopulmonary resuscitation
-fixed & dilated pupils
-GCS of 3

what is the second most common form of pediatric CA

brain tumors (astrocytoma and medullablastoma)

what are common symptoms of brain tumors

-HA
-N/V
-irritability
-balance disturbance
-ataxia
-seizures
-hemiparesis
-visual disturbances

give a brief description of the pediatric rancho levels of consciousness I-V

I: oriented to self, surroundings, time, & place/interacts w/ environment
II: demos awareness of environment & is responsive to it
III: gives localized response to sensory stimuli
IV: gives generalized response to sensory stimuli
V: no response to stimuli

when can you utilize MMT on a child with an ABI

typically can if child is > 7 & can follow 1 step commands

what are 5 postural/balance tests used in children with an ABI

-pediatric CTSIB (8+ y/o)
-segmental assessment of trunk control (SATCo)
-functional reach test
-TUG
-BOT2

how will autonomic instability following ABI present as

-tachycardia
-abnormal heart rhythm
-decreased HR variability w/ activity

what are the 4 stages of recovery that ABI interventions are based on

1. non-response to early response stage
2. vegetative state & minimally conscious state
3. agitation/confused stage
4. higher-level response stage

what position should be avoided when tx contractures in the non-response to early response stage & why

supine; or limited because it causes reflex hyperactivity & dystonic posturing

what are positive positions for muscle tone mgmt

SLing & semi prone

when can supported sitting & standing be initiated in non-response to early response stage of recovery?

once VS are stable at rest

what are the benefits of supported standing

-joint loading
-can facilitate muscle contraction/co-contraction
-stimulates bowel mvmts & release of urine
-improves lung expansion & ventilation

what is goal of a standing program in a pt who is in non-response to early response stage of recovery that will allow for max benefit?

have child standing for 45-60mins, 5 days/week for max benefit until they are able to complete standing w/o external support

what is the diagnostic criteria for intellectual disability?

limitations in intellectual functioning (IQ score of 70-75 or below) & adaptive behaviors (conceptual/social/practical skills)

what is considered most common SINGLE cause of human birth defects & is most common cause of ID?

down syndrome

What is the etiology of DS via autosomal trisomy of 21st chromosome?

3 copies of chromosome 21 due to faulty meiosis (cell division)
95% of DS

What is the etiology of DS via translocation?

long arm of chromo 15, 21, or 22 breaks off & attaches to another
3-4% of DS

What is the etiology of DS via mosaicism?

-faulty cell division after fertilization causing only a portion of individual's cells to be affected
-results in milder clinical presentation
1% of DS

what is the neuroanatomy in an individual w/ DS characterized by?

-overall reduction in brain weight
-microcephaly (smaller convulsions w/in brain, motor cortex abnormalities, lack of myelination)

list the 8 common physical features of DS

-Flat facial features (nose & small mouth)
-Upward slanting eyes, epicanthal folds of upper eyelid
-Toes short w/ a wide space b/t 1st & 2nd toes
-Excess skin at nape of neck
-Brachycephaly (back of head is slightly flattened, due to larger fontanels w/ delayed closure)
-Small ears
-Wide, short hands w/ short fingers
-Single midpalmar crease (Simian crease)
-White spots on colored part of eye (Brushfield spots)

what are the 2 most common congenital cardiac anomalies associated w/ DS?

-atrial septal defect
-ventricular septal defect

What is the pathophysiology of atrial septal defect?

Abnormal opening b/t L & R atria:
-Blood shunted L atrium → R atrium
-Slow progression of damage to heart & lungs

What is the pathophysiology of ventricular septal defect?

Abnormal opening b/t L & R ventricles
-Blood shunted L ventricle → R ventricle
-Increases BF thru R ventricle
-May lead to pulmonary hypertension

what are the signs of ventricular septal defect in infants (4)

-severe respiratory distress
-diaphoresis
-fatigability (esp. during feeding)
-low weight

at what age of a typically developing child will achieve rolling from supine to prone vs what age do 50%-95% of children w/ DS achieve rolling from supine to prone?

-typical: 3-4 months
-DS: 6-9 months

at what age of a typically developing child will achieve sitting vs what age do 50%-95% of children w/ DS achieve sitting?

-typical: 5-6 months
-DS: 10-15 months

at what age of a typically developing child will they creeping in quadruped vs what age do 50%-95% of children w/ DS achieve creeping in quadruped?

-typical: 7-10 months
-DS: 17-29 months

at what age of a typically developing child will achieve walking 15 ft vs what age do 50%-95% of children w/ DS achieve walking 15 ft?

-typical: 12 months
-DS: 24-40 months

describe/list the 5 MSK characteristics of DS

-slower rxn times during mvmt
-hyperflexibility
-ligamentous laxity (recurrent patellar dislocation, excessive foot pronation, scoliosis)
-hip complications (slipped capital femoral epiphyses, pelvis hypoplasia w/ shallow acetabular angle, dislocation risk)
-shorter stature

What are the gait characteristics of DS

-wide BOS
-out-toeing
-smaller step lengths
↑ knee flexion at contact
-hyperextension in stance
↓ single limb support
↑ hip flexion posture

what is Atlantoaxial instability in DS & when are individuals considered symptomatic w/ AAI?

-subluxation b/t C1 & C2 due to ligamentous laxity or odontoid maldevelopment
-considered symptomatic if sublux of cervical vertebrae is 6-10 mm

what are the clinical changes associated w/ AAI?

-Hyperreflexia & Clonus
(+) Babinski's sign
-Torticollis, reluctance to move neck
-Gait changes
-Changes in sensation
-Loss of bladder & bowel control
↓ in motor skills & strength

what are some activity-focused standardized tests?

-GMFM
-alberta infant motor scale (AIMS)
-peabody
-PEDI-CAT
-BOT-2

what are 2 participation and activity standardized tests

-children assessment of participation & enjoyment (CAPE)
-preferences for activities of children (PAC)

what 2 objective measures are valid & reliable for individuals w/ DS?

-6MWT
-TUG