16 - kids with special needs

What is special needs?

an umbrella term to encompass children who require special attention and specific necessities that other children do not

What are the categories of special needs?

1. medical

2. behavior

3. development

4. learning

5. mental health

What is Attention Deficit/Hyperactivity Disorder (ADHD)?

a chronic condition marked by persistent inattention, hyperactivity, and sometimes impulsivity

What gender is ADHD more common in?

boys

How does ADHD manifest in boys vs girls?

boys: impulsivity and hyperactivity → disruptive behavior

girls: inattentiveness rather than disruptive

How do vision problems correlate with ADHD?

a lot of times vision issues are diagnosed as ADHD

How should you adjust your exam for an ADHD child?

try to keep the attention of child

-go quick

-vary targets

-keep area clean

What is oppositional defiant disorder (ODD)?

an ongoing pattern of uncooperative, disobedient, defiant, and hostile behavior towards people in authority that lasts >6months

When does oppositional defiant disorder (ODD) start?

around age 8, but can start as early as preschool

What causes oppositional defiant disorder (ODD)?

combo of biological, physiological, and social factors

What can oppositional defiant disorder (ODD) lead to?

can lead to conduct disorder

What is conduct disorder?

repetitive and persistent pattern of behavior in which the basic rights of others or societal norms or rules are violated

What criteria is needed to diagnose conduct disorder in a child?

3 or more of the following in the last 12 months:

-aggression to people and animals

-destruction of property

-deceitfulness or theft

-serious violation of rules

When can conduct disorder manifest?

in childhood or early adulthood

How should you alter your exam for a conduct disorder patient?

do not have them look at you as authority → make sure they know you are trying to help them

What is intellectual and developmental disabilities (IDD)?

group of conditions that cause disability characterized by significant limitations both in intellectual functioning, and in adaptive behavior, covering a wide range of everyday social and practical skills

When does IDD manifest ?

before the age of 18

How is IDD classified?

classified as an IQ ≥ 2SD below the mean (≤70-75)

What are examples of conditions that IDD encompasses?

1. Down syndrome

2. autism spectrum disorders

how is severity of IDD quantified by IQ?

mild: IQ 70-55

moderate: IQ 55-35

severe: IQ 35-20

profound: IQ<20

What is Down syndrome?

condition when an individual has a full or partial extra copy of chromosome 21

What are the 3 types of Down syndrome?

1. trisomy 21

2. translocation

3. mosaicism

What is translocation Down syndrome?

long arm of 21 is attached to another chromosome (often chromosome 14)

What is mosacisim Down syndrome?

not all cells contain an extra chromosome

What is a risk factor for Down syndrome?

advanced maternal age

What are the medical conditions associated with Down syndrome?

1. congenital heart defects

2. Hirschsprung's disease - GI issues for babies

3. hearing loss

4. thyroid conditions → hypothyroidism

5. childhood leukemia

6. alzheimers disease

How has the life expectancy changed for people with down syndrome?

80's → 25 years old

today → 60 years old

What are the physical characteristics of Down syndrome?

slanted eyes

flat nasal bridge

flat + wide face

short neck

small chin + mouth

large tongue

short stature

excessive joint flexibility

short fingers

What is the average IQ for someone with Down syndrome?

50 → can range from mild ID to severe ID

what is the IQ for someone with mosaic DS?

10-30 higher than avg IQ of 50

How is language affected in those with Down syndrome?

receptive language is better than expressive

many have stutter or rapid and irregular speech pattern

What are the ocular associations with Down syndrome?

significant RE, keratoconus

worse than normal VA

accommodative insufficiency

strabismus

amblyopia

nystagmus

Brushfield spots

prominent epicanthal folds

blepharitis

optic nerve changes

What RE is common with people with down syndrome?

failure of emmetropization

>1 D cyl

What are Brushfield spots?

focal areas of iris hyperplasia surrounded by relative hypoplasia → more common in light irides

What type of blepharitis is seen in those with Down syndrome?

chronic seborrheic form that is very resistant to treatment → leads to excessive eye rubbing

How is the optic nerve different in those with Down syndrome?

1. increased # of vessels at disc margin

2. spoked vessel pattern

3. hypoplasia

What is autism spectrum disorder (ASD)?

group of complex disorders of brain development characterized by difficulties in social interaction, verbal and non-verbal communication, and repetitive behaviors

what diseases are included in ASD?

1. autistic disorder

2. pervasive developmental disorder

3. Asperger syndrome

When do signs and symptoms start in ASD?

around 2-3 years old

What gender is more common in ASD?

boys

What is the cause of ASD?

combination of autism risk genes and environmental factors influencing early brain development

What are the environmental stresses/factors that contribute to ASD?

1. advanced paternal age

2. maternal illness during pregnancy

3. oxygen deprivation during birth

How can the risk of autism be reduced?

prenatal vitamins with folic acid before conception and during pregnancy

What are the signs of ASD?

no big smiles or joyful expressions by 6 months

no back-and-forth sharing of sounds, smiles, or facial expression by 9 months

no babbling by 12 months or back-and-forth gestures (pointing, reaching, waving) by 12 months

no words by 16 months

no meaningful two-word phrases by 24 months

any loss of speech, babbling, or social skills at any age

What is Modified Checklist for Autism in Toddlers (M-CHAT)?

screening tool questionnaire that parents can answer that determines risk of ASD

Who makes an ASD diagnosis?

multi-disciplinary team:

1. psychologist

2. pediatrician

3. speech and language pathologist

4. occupational therapist

What sensory issues are seen in ASD?

can be hyper or hypo sensitivities → senses take in too much or too little info from surrounding environment

What is the main treatment for ASD?

early-intervention programs

What are the ocular associations with ASD?

1. significant RE

2. amblyopia

3. strabismus

What parts of the exam may be difficult for a patient with ASD?

IOP only

What are the exam strategies for a patient with ASD?

1. ask about sensitivities

2. ask questions with 2 choices of positive behavior

shaping

3. high probability vs low probability

What is shaping?

behavior development by reinforcements of attempts that are closer and closer to desired behavior

ex: BIO light shine first on leg, then shoulder, then face, then finally eyes

What is high probability vs low probability request?

requests are first made to do a task that is likely to be done followed by a request that is less likely to be done to create momentum

ex: ask patient to tolerate resting headrest of iCare on arm before asking them to tolerate it on forehead

What is Asperger syndrome?

high functioning autism

What do people with Asperger syndrome have difficulty with?

1. social interactions and interests

2. motor development

What are signs of Asperger syndrome?

1. robotic speech

2. lack of eye contact

3. awkward movement or mannerism

4. inability to understand social/emotional issues

5. obsession with unusual topics

What is not affected in Asperger syndrome?

no delay in language or cognitive development

majority have no ID

often have above average vocabulary and intelligence

What is cerebral palsy?

neurological disorder that appears in infancy/early childhood caused by brain damage that permanently affects body movement and muscle coordination

What are examples of causes of brain damage that can lead to cerebral palsy in the first few months of life?

ischemic stroke

birth trauma/hypoxia

bacterial meningitis

viral encephalitis

head injury from MVA or fall

child abuse

How many patients with cerebral palsy have intellectual impairment?

40%