on 06-Feb-2017 (Mon)

Attention Deficit/Hyperactivity Disorder
Syllabus: Floet et al. Attention Deficit/Hyperactivity Disorder. Pediatrics in Review.
2010;31(2):56.
American Academy of Pediatrics. ADHD: Clinical Practice Guideline for the
Diagnosis, Evaluation and Treatment of Attention‐Deficit/Hyperactivty Disorder in
Children and Adolescents. Pediatrics. 2011;128(5):1007.
Introduction
• ADHD is a neurobehavioral disorder defined by symptoms of
inattention, hyperactivity, and impulsivity.
• There is a two‐ to three‐fold higher prevalence in boys than girls with
girls being more likely to be diagnosed with the inattentive‐type ADHD
• Can profoundly effect academic performance, social interactions and
well being
DSM5
Diagnostic Criteria for Attention Deficit/Hyperactivity Disorder
A. A persistent pattern of inattention and/or hyperactivity‐impulsivity
that interferes with functioning or development, as characterized by
(1) and/or (2):
1. Inattention: Six (or more) of the following symptoms have persisted
for at least 6 months to a degree that is inconsistent with
developmental level and that negatively impacts directly on social
and academic/occupational activities:
a. Often fails to give close attention to details or makes careless
mistakes in schoolwork, at work, or during other activities (e.g.,
overlooks or misses details, work is inaccurate).
b. Often has difficulty sustaining attention in tasks or play
activities (e.g., has difficulty remaining focused during lectures,
conversations, or lengthy reading).
c. Often does not seem to listen when spoken to directly (e.g., mind
seems elsewhere, even in the absence of any obvious
distraction).
d. Often does not follow through on instructions and fails to finish
schoolwork, chores, or duties in the workplace (e.g., starts tasks
but quickly loses focus and is easily sidetracked).
e. Often has difficulty organizing tasks and activities (e.g., difficulty
managing sequential tasks; difficulty keeping materials and
belongings in order; messy, disorganized work; has poor time
management; fails to meet deadlines).
f. Often avoids, dislikes, or is reluctant to engage in tasks that
require sustained mental effort (e.g., schoolwork or homework;
for older adolescents, preparing reports, completing forms,
reviewing lengthy papers).
g. Often loses things necessary for tasks or activities (e.g., school
materials, pencils, books, tools, wallets, keys, paperwork,
eyeglasses, mobile telephones).
h. Is often easily distracted by extraneous stimuli (for older
adolescents, may include unrelated thoughts).
i. Is often forgetful in daily activities (e.g., doing chores, running
errands; for older adolescents, returning calls, paying bills,
keeping appointments).
j. Hyperactivity and impulsivity: Six (or more) of the following
symptoms have persisted for at least 6 months to a degree that
is inconsistent with developmental level and that negatively
impacts directly on social and academic/occupational activities:
a. Often fidgets with or taps hands or feet or squirms in seat.
b. Often leaves seat in situations when remaining seated is
expected (e.g., leaves his or her place in the classroom, in the
office or other workplace, or in other situations that require
remaining in place).
c. Often runs about or climbs in situations where it is
inappropriate. (Note: In adolescents, may be limited to feeling
restless.)
d. Often unable to play or engage in leisure activities quietly.
e. Is often "on the go," acting as if "driven by a motor" (e.g., is
unable to be or uncomfortable being still for extended time, as
in restaurants, meetings; may be experienced by others as being
restless or difficult to keep up with).
f. Often talks excessively.
g. Often blurts out an answer before...

Autism Spectrum Disorder
Syllabus: Johnson C et al. Identification and Evaluation of Chidlren with Autism
Spectrum Disorders. Pediatrics. 2007;120(5):1183.
Harrington et al. The Clinician’s Guide to Autism. Pediatrics in Review.
2014;35(2):62.
Simms et al. Autism, Language Disorder, and Social (Pragmatic) Communication
Disorder: DSM‐V and Diferential Diagnosis. Pediatrics in Review. 2015;36(8):355.
Introduction
• The essential features of autism spectrum disorder are persistent
impairment in reciprocal social communication and social interaction,
and restricted, repetitive patterns of behavior, interests, or activities.
• These symptoms are present from early childhood and limit or impair
everyday functioning
• Social skills deficits can be noticed in infancy with aversion to cuddling
and lack of acknowledgement of the caregiver
• Also can involve language delays/deficits, motor signs (e.g.,
stereotypies, toe walking), sensory deficits (e.g., intolerance to sound)
• Cognitive abilities vary; typically difficulties with reasoning/planning,
greater abilities in rote memory
DSM5
Criteria for Autism Spectrum Disorder
A. Persistent deficits in social communication and social interaction
across multiple contexts, as manifested by the following, currently or
by history (examples are illustrative, not exhaustive; see text):
1. Deficits in social‐emotional reciprocity, ranging, for example, from
abnormal social approach and failure of normal back‐and‐forth
conversation; to reduced sharing of interests, emotions, or affect; to
failure to initiate or respond to social interactions.
2. Deficits in nonverbal communicative behaviors used for social
interaction, ranging, for example, from poorly integrated verbal and
nonverbal communication; to abnormalities in eye contact and
body language or deficits in understanding and use of gestures; to a
total lack of facial expressions and nonverbal communication.
3. Deficits in developing, maintaining, and understanding
relationships, ranging, for example, from difficulties adjusting
behavior to suit various social contexts; to difficulties in sharing
imaginative play or in making friends; to absence of interest in
peers.
B. Restricted, repetitive patterns of behavior, interests, or activities, as
manifested by at least two of the following, currently or by history
(examples are illustrative, not exhaustive; see text):
1. Stereotyped or repetitive motor movements, use of objects, or
speech (e.g., simple motor stereotypies, lining up toys or flipping
objects, echolalia, idiosyncratic phrases).
2. Insistence on sameness, inflexible adherence to routines, or
ritualized patterns of verbal or nonverbal behavior (e.g., extreme
distress at small changes, difficulties with transitions, rigid thinking
patterns, greeting rituals, need to take same route or eat same food
every day).
3. Highly restricted, fixated interests that are abnormal in intensity or
focus (e.g., strong attachment to or preoccupation with unusual
objects, excessively circumscribed or perseverative interests).
4. Hyper‐ or hyporeactivity to sensory input or unusual interest in
sensory aspects of the environment (e.g., apparent indifference to
pain/temperature, adverse response to specific sounds or textures,
excessive smelling or touching of objects, visual fascination with
lights or movement).
C. Symptoms must be present in the early developmental period (but may
not become fully manifest until social demands exceed limited
capacities, or may be masked by learned strategies in later life).
D. Symptoms cause clinically significant impairment in social,
occupational, or other important areas of current functioning.
E. These disturbances are not better explained by intellectual disability
(intellectual developmental disorder) o...

Learning Disorders
Syllabus: Rimrodt et al. Learning Disabilities and School Failure. Pediatrics in
Review. 2011;32(8):315.
Byrd R. School Failure: Assessment, Intervention, and Prevention in Primary Care
Pediatrics. Pediatrics in Review. 2005;26(7):233.
• Represent a disability based on a descrepency between a person’s
intellectual ability and actual academic performance
• Further specificed into the particular area of academic function
affected:
o Mathematics disorder
o Reading disorder
o Disorder of reading expression
• Any child who has school problems and is suspected of having a
learning disability should be referred for a comprehensive
psychoeducational evaluation
• Accomodations can be made at school through the Identification,
Placement, and Review Committee (IPRC). The IPRC will:
o decide whether or not a student should be identified as exceptional
o identify the areas of a student’s exceptionality
o decide an appropriate placement for a student
o review identification and placement at least once per school year
• An IEP (Individual Education Plan) is developed (in consultation with
parents and the student) for each student who has been identified as
exceptional by the IPRC process. An IEP is a written plan that describes
the strengths and needs of the student, services established to meet
that student’s needs, and how these should be delivered

Bullying
Syllabus: Lamb et al. Approach to Bullying and Victimization. Canadian Family
Physician. 2009;55(4):356.
Introduction
• Defined as the use of power or aggression to cause distress or control
of another
• Can be direct (face‐to‐face) or indirect (gossip, exclusion)
• Negative actions can include:
o Physical actions (punching, kicking, biting)
o Verbal actions (threats, name calling, insults)
o Social exclusion (spreading rumours, gossiping, excluding)
• Actions are repeated and the intensity or duration establishes
dominance

History
• When a physician identifies a possible bullying situation, the following
questions can help determine what type of help may be appropriate
o Who do you bully/who bullys you?
o What do you do to others/what do others do to you? (e.g. gossiping,
insults, hitting, etc.)
o When and how often do you bully/are you bullied?
o Where do you bully/where are you bullied?
o Why do you bully others/why do you think you are bullied?
o How do you think the kids feel when you bully them or how do you
feel when you are bullied?
Management
• Comprehensive strategies that encompass the school, family and
community are most likely to be effective
o establish a social school environment that promotes safety
o provide access to health and mental health services
o integrate school, family and community prevention efforts
o provide training to enable school staff to promote safety and
prevent violence effectively

Toilet Training
Syllabus: Clifford et al. Toilet Learning: Anticipatory Guidance with a child‐oriented
approach. Paediatrics and Child Health. 2000;5(6):333.
Feldman. Managing primary nocturnal enuresis. Paediatr Child Health. 2005;
10(10):611.
Bayne et al. Nocturnal enuresis: An approach to assessment and treatment. Peditrics
in review. Pediatrics in Review. 2014; 35(8):327.
Austin et al. Dysfunctional Voiding. Pediatrics in Review. 2000;21(10):336.
Har et al. Encoperesis. Pediatrics in Review. 2010;31(9):368.
Signs of a child’s toilet learning readiness
• Can understand and follow simple instruction
• Diaper is consistently dry for 2 to 3 hours at a time or after naps
• Bowel movements are somewhat regular and predictable
• Seems uncomfortable with soiled diapers and wants to be changed
• Recognizes and tells or shows need to urinate or stool
• Can walk to bathroom and pull pants up and down
• Is stable on potty (good trunk support)
• Interested and motivated to learn how to use the potty
• Shows interest in 'big kid' underwear
- Child does not need to show all of the signs, but at least a few should be
present to indicate the child is ready for toilet training
- Average age for a child to be toilet trained is between 2 to 3 years old
- Advise parents to expect accidents during initial training

Sleep Requirements

Newborns
• Should sleep on back in crib with flat surface, no pillows or soft items
• In parents’ room for first 6 months
Older babies
• Maintain regular daytime and bedtime schedule
• Start consistent bedtime routine
• Avoid putting baby to bed with a bottle

Sleep Problems
Night terrors
• Parasomnia that occurs in first third of night
• High to extreme autonomic agitation
• High arousal threshold, agitated if awakened
• No daytime sleepiness or recall of event
Nightmares
• Occur in last third of night during REM sleep
• Mild to high autonomic arousal/agitation
• Low arousal threshold, agitated after event
• Can have daytime sleepiness and frequent, vivid recall of event
• Very common
BEARS Screening Tool for Pediatric Sleep Disorders

Sleep associations
• Infant or toddler child has learned to fall asleep only under certain
conditions or has specific sleep associations that require parental
intervention, such as being rocked or fed, which are usually readily
available at bedtime
• During the night, when the infant or toddler awakens, they are not able
to get back to sleep ("self‐soothe") unless those same conditions are
available
90
o The infant then "signals" the caregiver by crying or coming into the
parents' bedroom if the child is no longer in a crib until the
necessary associations are provided
o Ferber method advocates that at bedtime child is put in bed while
they are drowsy, but still awake, to help them learn how to fall
asleep on their own (self‐soothe)

Colic
Syllabus: Cohen et al. Colic. Pediatrics in Review. 2012;33(7):332.
• Infantile colic is defined as
o paroxysms of irritability, fussiness or crying that start and stop
without obvious cause;
o episodes lasting 3 h or more per day and occurring at least three
days per week for at least three weeks; and
o no failure to thrive
• Peaks at 6 weeks of age and typically ends by 3‐4 months
• Crying is most frequent in the late afternoon or evening
• Holding or rocking and offering a pacifier might help
• There is no evidence that medicines really help with colic
• There is no or insufficient evidence to support dietary changes
including probiotics, lactose free diet, soy formulas
• If there is a concern about cow’s milk protein allergy, a time limited
(two week) trial of hypoallergenic formula or elimination of cow’s milk
from the maternal diet can be undertaken

Children get many different kinds of rashes-many, though not all, related to infections. Below are
descriptions and photos of rashes associated with fever.
Erythema
infectiosum
Also called fifth disease, this is caused by parvovirus B19.
There is frequently an associated low-grade fever (37.8-38.3 degrees C, or
100-101 degrees F), with a rash appearing seven to ten days later.
The characteristic rash starts as facial erythema-the "slapped cheek"
appearance. This can spread to the trunk and have an erythematous macular
appearance. Central clearing of the rash appears, giving a lacy appearance.
The rash often lasts longest on the extremities, where it has a lacy, reticular
appearance.
People with fifth disease can also develop pain and swelling in their joints
(polyarthropathy syndrome).
Individuals with underlying immune deficiencies who are exposed to this virus
are at risk for developing aplastic anemia.

Children get many different kinds of rashes-many, though not all, related to infections. Below are
descriptions and photos of rashes associated with fever.
Measles
After a prodrome of fever (over 38.3 C, or 101 F), cough, coryza, and
conjunctivitis, this maculopapular rash starts on the neck, behind the ears, and
along the hairline.
The rash spreads downward, reaching the feet in two or three days.
The initial rash appears on the buccal mucosa as red lesions with bluish white
spots in the center (known as Koplik spots). These have frequently
disappeared by the time the patient presents to medical attention.
Immunization is very effective in preventing this infection.

Children get many different kinds of rashes-many, though not all, related to infections. Below are
descriptions and photos of rashes associated with fever.
Meningococcemia
Caused by the bacteria Neisseria meningitidis, onset is abrupt and
accompanied by fever, chills, malaise, and prostration.
The initial rash may be urticarial, maculopapular, or petechial (marked
by small, purplish, hemorrhagic spots).
In fulminant cases, it can become purpuric, marked by large
hemorrhages into the skin.
Immunization is effective in preventing this infection.

Children get many different kinds of rashes-many, though not all, related to infections. Below are
descriptions and photos of rashes associated with fever.
Roseola
This macular or maculopapular rash, also called exanthem subitum,
starts on the trunk and spreads to the arms and neck.
There is usually less involvement of the face and legs.
The rash is preceded by three or four days of high fevers, which end
as the rash appears.
Usually seen in children less than two years old.

Children get many different kinds of rashes-many, though not all, related to infections. Below are
descriptions and photos of rashes associated with fever.
Scarlet fever
This rash, caused by infection with group A Streptococcus, consists of
very fine papules, often described as feeling like sandpaper.
It is erythematous, but blanches.
The rash starts in the groin, axillae, and neck, but rapidly spreads.
The fever can be high, and the disease is usually self-limited, lasting
less than 10 days.
It is important to treat with antibiotics to prevent non-suppurative
complications of strep, including rheumatic fever.

Children get many different kinds of rashes-many, though not all, related to infections. Below are
descriptions and photos of rashes associated with fever.
Varicella
The rash, also known as chicken pox, starts on the trunk and spreads
to the extremities and head.
Each lesion progresses from an erythematous macule to papule
to vesicle to pustule, and then crusts over.
Lesions at various stages of development are seen in the same area of
the body.
There is usually a mild fever.
The disease is self-limited, lasting about a week.
Immunization is effective in preventing this infection.

Financial analysis is the process of examining a company’s performance in the context of its industry and economic environment in order to arrive at a decision or recommendation.

Overall, a central focus of financial analysis is evaluating the company’s ability to earn a return on its capital that is at least equal to the cost of that capital, to profitably grow its operations, and to generate enough cash to meet obligations and pursue opportunities.

Basic financial statement analysis provides a foundation that enables the analyst to better understand information gathered from research beyond the financial reports.

The nature of the information collected will vary on the basis of the individual decision to be made (or the specific purpose of the analysis) but will typically include information about the economy, industry, and company as well as information about comparable peer companies.

Much of the information will likely come from outside the company, such as economic statistics, industry reports, trade publications, and databases containing information on competitors

Financial reports include financial statements along with supplemental disclosures necessary to assess the company’s financial position and periodic performance.

Financial statements are the result of an accounting recordkeeping process that records economic activities of a company, following the applicable accounting standards and principles.

Financial statements are almost always audited by independent accountants who provide an opinion on whether the financial statements present fairly the company’s performance and financial position in accordance with a specified, applicable set of accounting standards and principles.

A complete set of financial statements include a statement of financial position (i.e., a balance sheet), a statement of comprehensive income (i.e., a single statement of comprehensive income or an income statement and a statement of comprehensive income), a statement of changes in equity, and a statement of cash flows

The statement of changes in equity provides additional information regarding the changes in a company’s financial position.

the accompanying notes or footnotes to the financial statements are required and considered an integral part of a complete set of financial statements.

The additional information provided may include:

A letter from the chairman of the company,

A report from management discussing the results (typically called management discussion and analysis or management commentary),

An external auditor’s report providing assurances,

A governance report describing the structure of the company’s board of directors, and a corporate responsibility report.

The balance sheet (also called the statement of financial position or statement of financial condition )

Depending on the form of the organization, owners’ equity may be referred to as “partners’ capital” or “shareholders’ equity.”

IFRS require companies to present classified balance sheets that show current and non-current assets and current and non-current liabilities as separate classifications. However, IFRS do not prescribe a particular ordering or format, and the order in which companies present their balance sheet items is largely a function of tradition.

Volkswagen presents non-current assets before current assets, owners’ equity before liabilities, and within liabilities, non-current liabilities before current liabilities. This method generally reflects a presentation from least liquid to most liquid. In other countries, the typical order of presentation may differ. For example, in the United States, Australia, and Canada, companies usually present their assets and liabilities from most liquid to least liquid. Cash is typically the first asset shown, and equity is presented after liabilities.

The income statement presents information on the financial results of a company’s business activities over a period of time.

Other income includes gains, which may or may not arise in the ordinary activities of the business.

Expenses reflect outflows, depletions of assets, and incurrences of liabilities that decrease equity.

Net income (revenue plus other income minus expenses) on the income statement is often referred to as the “bottom line” because of its proximity to the bottom of the income statement.

Income statements are reported on a consolidated basis, meaning that they include the income and expenses of subsidiary companies under the control of the parent (reporting) company.

The income statement is sometimes referred to as a statement of operations or profit and loss (P&L) statement

The basic equation underlying the income statement is Revenue + Other income – Expenses = Income – Expenses = Net income.

In general terms, when one company (the parent) controls another company (the subsidiary), the parent presents its own financial statement information consolidated with that of the subsidiary.

When a parent company owns more than 50 percent of the voting shares of a subsidiary company, it is presumed to control the subsidiary and thus presents consolidated financial statements.

Each line item of the consolidated income statement includes the entire amount from the relevant line item on the subsidiary’s income statement (after removing any intercompany transactions); however, if the parent does not own 100 percent of the subsidiary, it is necessary for the parent to present an allocation of net income to the minority interests.

Minority interests, also called non-controlling interests, refer to owners of the remaining shares of the subsidiary that are not owned by the parent.

The share of consolidated net income attributable to minority interests is shown at the bottom of the income statement along with the net income attributable to shareholders of the parent company.

The income statement is sometimes referred to as a statement of operations or profit and loss (P&L) statement .

Operating profit represents the results of the company’s usual business activities before deducting interest expense or taxes.

Operating profit (also called operating income) is thus often referred to as earnings before interest and taxes (EBIT)

Earnings per share numbers represent net income attributable to the class of shareholders divided by the relevant number of shares of stock outstanding during the period.

Basic earnings per share is calculated using the weighted-average number of common (ordinary) shares that were actually outstanding during the period and the profit or loss attributable to the common shareowners.

Diluted earnings per share uses diluted shares —the number of shares that would hypothetically be outstanding if potentially dilutive claims on common shares (e.g., stock options or convertible bonds) were exercised or converted by their holders—and an appropriately adjusted profit or loss attributable to the common shareowners.

Volkswagen has two types of shareholders, ordinary and preferred, and presents earnings per share information for both, although there is no requirement to present earnings per share information for preferred shareowners.

An analyst examining the income statement might note that Volkswagen was profitable in both years. The company’s profitability declined substantially in 2009, primarily because of lower sales and reduced gross profit. This was not unexpected given the global financial and economic crisis in that year. A better understanding of Volkswagen’s profitability could likely be gained by examining income statements over a longer time period. The analyst might formulate questions related to profitability, such as the following:

• Is the change in revenue related to an increase in units sold, an increase in prices, or some combination?

• If the company has multiple business segments (for example, Volkswagen’s segments include passenger cars, light commercial vehicles, and financial services, among others), how are the segments’ revenue and profits changing?

• How does the company compare with other companies in the industry?

Answering such questions requires the analyst to gather, analyze, and interpret information from a number of sources, including, but not limited to, the income statement.

3.1.2.2. Other Comprehensive Income

Comprehensive income includes all items that impact owners’ equity but are not the result of transactions with shareowners. Some of these items are included in the calculation of net income, and some are included in other comprehensive income (OCI). Under IFRS, when comprehensive income is presented in two statements, the statement of comprehensive income begins with the profit or loss from the income statement and then presents the components of other comprehensive income. Although US generally accepted accounting principles (US GAAP) indicate a preference for this type of presentation when a single statement of comprehensive income is not presented, they permit companies to present the components of other comprehensive income in the statement of changes in equity.5

Exhibit 6 presents the statement of comprehensive income of the Volkswagen Group from its Annual Report 2009.

Exhibit 6. Statement of Comprehensive Income of the Volkswagen Group for the Period 1 January to 31 December

€ million	2009		2008
Profit after tax	911		4,688
Exchange differences on translating foreign operations:
Fair value changes recognized in other comprehensive income	917		–1,445
Transferred to profit or loss	57
Actuarial gains/losses	–860		190
Cash flow hedges:
Fair value changes recognized in other comprehensive income	683		1,054
Transferred to profit or loss	–908		–1,427
Available-for-sale financial assets (marketable securities):
Fair value changes recognized in other comprehensive income	200		–330
Transferred to profit or loss	71		100
Deferred taxes	216		145
Share of profits and losses of equity-accounted investments recognized directly in equity, after tax	30		–188
Other comprehensive income	406		–1,901
Total comprehensive income	1,317		2,787
Of which attributable to
Shareholders of Volkswagen AG	1,138		3,310
Minority interests	179		–523

Exhibit 6 shows that other comprehensive income, although smaller in absolute terms than profit after tax (net income), had a significant effect on total comprehensive income. In 2009, other comprehensive income represented approximately 31 percent of total comprehensive income and was approximately 45 percent of the size of profit after tax (net income). In 2008, other comprehensive income was negative (a loss) and was approximately 41 percent of the size of profit after tax (net income) in absolute terms. The statement of comprehensive income will b

...

Comprehensive income includes all items that impact owners’ equity but are not the result of transactions with shareowners.

Under IFRS, when comprehensive income is presented in two statements, the statement of comprehensive income begins with the profit or loss from the income statement and then presents the components of other comprehensive income.