Pediatrics

• Cerebellum


  • Triples in size in first year, reflects extensive motor development infants experience
• Visual areas of cortex


  • Grow in first year, explains rapid development of vision from seeing inches away at birth to full binocular vision by end of year 1
• Hippocampus


  • Significant growth in first year, allows infants to rapidly advance in learning and memory, build on skills and navigate environment
• Language circuits in frontal and temporal lobes


  • Consolidate in first year, at birth infants recognize mother's voice from in utero, by end of year 1 they understand various communication and range of tones, communication skills progress rapidly
• Years 1 and 2 are years of substantial brain growth that slows in the 2nd year of life, before the brain stabilizes in size in early childhood
• Prefrontal cortex


  • Reaches peak synaptic density around ages 3-5, then synaptic connections begin pruning

  
• Prefrontal cortex


  • Strongly connected with other brain regions but processes are not yet efficient or strengthened at age 3

  
• Children at age 3

  • Have more cognitive flexibility and better understanding of cause and effect compared to first 2 years, these functions continue to advance throughout childhood
• Children at age 3

  • Are better able to use past experiences to interpret present events
• Middle childhood (6-11 years)


  • Thickening of cerebral cortex in temporal and frontal lobes
  • Brain volume stabilizes
  • Maturation of occipital and temporal lobes
  • Increased efficiency of pathways in prefrontal cortex, improved attention, reasoning, and cognitive control

  
• Adolescence (12-18 years)


  • Amygdala develops rapidly ahead of brain regions that help control it (emotions)
  • Thickening of corpus callosum, brain can process information more quickly
  • Prefrontal cortex is starting to mature, can begin to better control intense emotions
  • Parietal lobe reaches maturation around age 12
  • Synapses at adult density but not yet complete with maturation (myelination)
  • Frontal lobe and prefrontal cortex do not reach maturation until mid-20s

  
• ACEs have the potential to negatively alter brain structures and functions
• Certain populations are more likely to experience ACEs
• 4 is the baseline number of ACEs correlated with elevated risk of negative health outcomes
• 1 in 6 adults reports experiencing 4 or more ACEs
• Significance of 4


  4 or more ACEs
• The U.S. spends billions of dollars annually on subsequent treatment of negative health outcomes associated with ACEs
• Early adverse experiences can impair a child's development, with the amount of adversity a child experiences positively correlated with the odds of having a delay in cognitive, language, or emotional development
• Attention deficits, emotional dysregulation, and oppositional behaviors in children and adolescents may be rooted in ACEs and toxic stress
• Individuals with ACEs are more likely to have difficulty engaging in their communities in the same capacity of adults without ACEs
• Domestic violence


  • Grey matter changes in visual cortex; decreased integrity of left inferior longitudinal fasciculus – which determines emotional response to visual stimulus
• Emotional abuse


  • Thinning of parts of cingulate cortex and bilateral precuneus – regions involved in self-awareness and self-evaluation
• Verbal abuse


  • Reduced grey matter volume in the left auditory cortex and abnormalities in the left arcuate fasciculus – an important language-processing pathway
• Sexual abuse

  • Alterations in visual cortex, particularly parts involved in facial recognition, and thinning in portions of somatosensory cortex involved in touch sensation of genital area
• Though a term continuously revisited due to varying operational definitions – the resilience of the brain seems to be the mediating factor

  
• Individuals without negative outcomes typically have more structural changes – indicating the compensation of the brain in response to adversity
• Not all individuals who have structural changes have psychiatric or other negative health outcomes
• Many individuals who experience ACEs have the described fundamental brain changes
• Core principles of trauma-informed approach to care

  • Patient empowerment
  • Patient choice
  • Maximizing collaboration among the patient, family, and healthcare team in organizational and treatment planning
  • Settings and activities that ensure a patient's physical and emotional safety
  • Trustworthiness through clear expectations about proposed treatment, who will provide services, and how care will be provided
• Key components of trauma-informed clinical practices

  • Involving patients in the treatment process
  • Screening for trauma
  • Training all team members in trauma-specific treatment approaches
  • Engaging referral sources and partnering organizations
• Core concepts for understanding traumatic stress

  • Traumatic experiences are inherently complex
  • Trauma occurs within a broad context that includes children's personal characteristics, life experiences, and current circumstances
  • Traumatic events often generate secondary adversities, life changes, and distressing reminders in children's daily lives
  • Children can exhibit a wide range of reactions to trauma and loss
  • Danger and safety are core concerns in the lives of children who have experienced trauma
  • Traumatic experiences affect the family and broader caregiving systems
  • Protective and promotive factors can reduce the adverse impact of trauma
  • Trauma and post-trauma adversities can strongly influence development
  • Developmental neurobiology underlies children's reactions to traumatic experiences
  • Culture is closely interwoven with traumatic experiences, response, and recovery
  • Challenges to the social contract, including legal and ethical issues, affect trauma response and recovery
  • Working with trauma-exposed children can evoke distress in providers that makes it more difficulty for them to provide good care
• Potential signs of adversity (not exhaustive)

  • Atypical attachment behavior: clinging to caregivers or detached from caregivers
  • Regressing to younger behavior
  • Changes in sleeping and eating patterns
  • Irritability, agitation, reactivity, aggression
  • Hyperactivity or hypo-reactivity (altered regulation and sensory processing)
  • Exaggerated fear or phobias
  • "High needs" or "attention seeking" behavior
  • Easily upset or inconsolable
  • Difficulty concentrating
  • Difficulty engaging with peers
  • Loss of previously mastered skills
  • Exaggerated "fight or flight" response
  • Withdrawal
  • Overly concerned with upsetting others or how others are feeling
  • Restlessness
  • Physical pains (stomach aches, back pain)
  • Hyper fixation or complete inability to recall periods of time
  • Persistent sense of shame or guilt
  • Low self esteem and sense of worth
• Visual motor development: Birth to 2 years

  • Birth to 6 months: Develops accurate reach, visually tracks, transfers objects hand to hand

  1. 12 months: Mouths toys, rolls ball to adult, points to toys, pokes with index finger, grasp small objects with finger tips

  12-18 months: Scribbles with crayon, stacks blocks, holds a toy in each hand, opens/shuts containers, points to pictures

  18-24 months: 4-5 piece puzzles, build towers (4 blocks), string beads, turn pages in a book, holds crayon with finger tips (brush grasp), makes simple strokes (straight line or emerging circle)
• Visual perception development: Birth to 2 years


  • Birth to 6 months: Explore visually and with mouth, touching textures with fingers

  1. 12 months: Explore with eyes and hands, discrimination of object hardness

  12 months - 3 years: Object manipulation leads to understanding of object shape, adjusts manipulation based on object shape
• Fine motor & manipulation development: 3-5 years


  • Development of in-hand manipulation by age 4, moving into functional use of drawing and cutting tools, developing from static to dynamic tripod grasp, increases in bilateral hand coordination, hand-eye coordination, and dexterity
• Fine motor & manipulation development: 6-10 years

  • Increasing precision with tool use and drawing, manipulate materials (e.g. folding, cutting, sorting, adhering), appropriate proportions and accuracy with drawing, increasing writing speed and accuracy
• Prewriting and handwriting development

  12-18 months: Scribbles and makes marks on paper

  2 years: Imitates horizontal, vertical, and circular marks; Colors in large forms

  3 years: Copies vertical and horizontal lines and circles

  1. 5 years: Copies cross, right oblique line, diagonal left oblique cross, some letters and numerals; Colors within the lines; Copies own name
  2. 6 years: Copies triangle, prints own name, copies most lower and uppercase letters
• Occupations

  The activities children engage in during daily life, including activities of daily living, instrumental activities of daily living, rest and sleep, education, work, play and leisure, social participation, and health management
• Performance skills


  Goal-directed actions that a person enacts when performing a task and that contribute to occupational engagement, including motor skills, process skills, social interaction skills, and emotional skills
• Performance patterns


  The acquired habits, routines, roles, and rituals used in the process of engaging consistently in occupations and can support or hinder occupational performance