recognition for CHOC’s cancer program is well-deserved. There’s nowhere else
I’d rather have gone through treatment than CHOC,” says 17-year-old Sydney
Sigafus, CHOC patient and cancer survivor. “Everyone who works at CHOC cares
about you as a person, not just a patient. I was included in every decision and
conversation about my care.”
Children’s Hospitals rankings were introduced by U.S. News in 2007 to help families of children with rare or
life-threatening diseases find the best medical care available. Only the
nation’s top 50 pediatric facilities are distinguished in 10 pediatric
specialties, based on survival rates, nurse staffing, procedure and patient
volumes, reputation and additional outcomes data. The availability of clinical
resources, infection rates and compliance with best practices are also factored
into the rankings.
“We understand how scary it can be for parents whose children are dealing with life-threatening illnesses or injuries. That’s why we are committed to the highest standards of care, safety and service,” says Dr. James Cappon, CHOC’s chief quality officer. “While we are proud of our accolades, including being named a best children’s hospital, we remain focused on preserving the magic of childhood for all kids, whether they are seriously ill or healthy, or somewhere in between.”
What can providers tell parents about the study’s findings?
Many parents ask me, “Will my child outgrow autism?” and I
always tell them that what we hope for is that with services and growth, the
child will improve so much that after as little as a few years, they no longer
meet the criteria for Autism Spectrum Disorder (ASD). Outgrowing the label may
mean they have learned to compensate or overcome some challenges like
socialization or repetitive movements. They may have little features left of
ASD, and what symptoms they do have, may cease to interfere with their development
or daily lives. When they have progressed to the point where they have outgrown
the label, any remaining traits may be so small that only a parent would
notice, but a new person who has just met the child wouldn’t pick up on
However, I advise my patients’ parents that if and when their
child outgrows the label of autism, they may still have other co-occurring
issues like anxiety, attention deficit hyperactivity disorder (ADHD) or
learning disabilities that require ongoing care.
So yes, indeed this study should give parents hope
surrounding a child’s ability to outgrow the autism label, despite their other
potential ongoing issues.
In some instances, schools may suggest a decrease in services because a child has improved and outgrown the label of autism. That same child may still be struggling with organization or learning certain subjects. Parents may be in a position to say that just because their child has outgrown the autism label doesn’t mean they do not have a need for additional support.
What does life look like for a child previously diagnosed with autism who is no longer on the spectrum?
Learning disabilities, obsessive compulsive disorder, and
attention deficit disorder are common among children with ASD. Rates of other
disorders are common among children with autism, including: gastrointestinal
disorders, ear infections, seizures and anxiety. They may clear up later in
life or become better managed, but they don’t necessarily go away at the same
time as their autism label.
Residual symptoms of these co-occurring diagnoses may last into adulthood. For example, a child may outgrow their ASD label but still have anxiety that can be managed by cognitive behavioral therapy.
Why is early
detection and early intervention of autism so important?
Early detection and intervention help many kids outgrow the
autism label in the future due to improvements with socialization and
repetitive behavior. It’s important for people to remember that just because
they have lost the autism label doesn’t mean they don’t have other diagnoses or
disorders that may require ongoing treatment.
There’s no question that early intervention makes a big
difference in helping kids with the potential to outgrow their ASD diagnoses
achieve that milestone even sooner. The trajectory has changed for many of
You open the exam room door to find an anxious mother pacing with her baby. Her son has been displaying sudden shivering moments, she says. She’s frightened that these episodes were epileptic seizures.
Indeed, watching a child shake and tremble suddenly is worrisome for any parent. But not every paroxysmal event is a seizure or neurological event.
Here are 11 such examples, and a guide to help pediatricians understand what the differential diagnosis is for seizures and other neurological events; recognize elements in the history that helps differentiate whether the paroxysmal spell is a seizure or neurological event or not; and learn what initial diagnostic workup is needed to guide management.
During these episodes, a child appears to stop breathing and may collapse, typically after a startling, frustrating or painful event. The child’s skin may be pale or purple in color, and he may show mild tonic or tonic-clonic movements. Recovery occurs in minutes. The behavior surfaces typically in children between ages 6 months and 2 years.
Though they may appear to be a seizure, these episodes are a physiological response, and not caused by electrical impulses in the brain.
Some factors to consider, however, that would call into question whether this is something other than breath-holding spells include a questionable or unclear trigger, progressively more frequent episodes, movements much more suggestive of a seizure, a very young age of onset, and a child with a developmental delay.
Children showing these red flags may require an EEG. For most, however, a workup is not typically needed, nor is treatment.
Almost all children outgrow breath holding and there is no neurological consequence.
2. Benign paroxysmal vertigo
During these episodes, a child, typically between 1 to 2 years of age, may become suddenly unsteady and fall. The child may become pale, vomit or cry, but retain consciousness. Events last minutes.
These events are considered an early migraine manifestation. Differential diagnoses include labyrinthitis, CNS tumor, epilepsy, unwitnessed head trauma and concussion, near-syncope, cardiac dysrhythmia
More worrisome are events that are unremitting and not episodic; include a loss of consciousness; show other neurological signs such as seizures, weakness or hearing loss; or are experienced by a child with a developmental delay can be more worrisome.
Workup for children exhibiting these events could include a brain MRI, ENT evaluation or EEG.
These episodes are typically not progressive or degenerative, but do indicate a likelihood for migraines in teen and adult years.
3. Shuddering attacks
Patients experiencing these events have shivering moments that last seconds, which can occur sporadically or multiple times a day. They occur most typically in infants ages 6 to 15 months, and they do not lose consciousness.
These events are behavioral, and differential diagnoses include seizure or tics.
Longer episodes; rhythmic twitching; a change of awareness or consciousness; and color change are red flags, as is an event experienced by a child with developmental delay or abnormal exam.
A video captured at home is often sufficient for diagnosis, and no workup is needed. No treatment is necessary for these events, and a child’s prognosis is excellent.
4. Infant gratification
This is a normal phenomenon, more commonly known as masturbation, that can include dystonic posturing, grunting, rocking, eidetic imagery and sweating. Typically experienced by children 2 months to 5 years of age, these events can occur sporadically or multiple times a day.
Children’s skin may change color and they may seem tired afterward. The event can be stopped in progress, but a child may get upset if the parents stop the behavior.
Red flags for this behavior include unresponsiveness, tonic-clonic movements or cyanosis, and a differential diagnosis is partial seizures.
A video captured at home is often sufficient for diagnosis, and no workup is needed. Treatment is behavioral based, and prognosis is excellent.
5. Staring spells
These episodes occur in children of any age, but are common in children with autism. The spells may look like day dreaming or inattention, but are often redirectable.
Often, the events are behavioral or related to frontal lobe processing. Differential diagnoses include absence or complex partial seizures. Episodes wherein children are not redirectable, show a change in coloring or behavior, or have a cognitive decline are more worrisome.
Workups include EEG, ADHD evaluation, neuropsychological evaluation for learning disabilities and cognitive abilities, or a psychological evaluation.
Treatment can include psychology or behavioral therapy, neuropsychology and appropriate educational setting, or stimulant medication as needed.
In general, a child’s prognosis is typically excellent. Children with ADHD have a generally good prognosis, but may have variable response to treatment with stimulant medications. A prognosis for those with learning disabilities depends on the severity, classroom setting and educational factors.
Shown in younger infants from birth to age 6 months, these events look like twisting and writhing movements that aren’t typically sudden. However, patients may show some sudden flexion and extension of the body, arms or legs. Children’s skin may redden.
Children exhibiting these events may have low muscle tone that contributes to relaxed muscle at esophageal-gastric junction.
Differential diagnoses include seizures, infantile spasms or movement disorders, and red flags include no association with feeding, stereotyped movements like jack-knifing or sudden flexion in clusters, or cyanosis.
Workup includes clinical diagnosis, further investigation following a finding of low tone on exam, sometimes upper GI or other GI studies, EEG or video-EEG monitoring.
Treatment includes H2 blockers or proton pump inhibitors.
Patients’ prognoses are generally excellent with symptoms resolving over time. However, for children with significant GI pathology or neuromuscular conditions, the prognosis is guarded.
7. Tics/Tourette’s syndrome
These episodes include the twitching of one muscle or a group of muscles, but rarely involve larger muscle groups. Though repetitive, they are not typically rhythmic or prolonged. They do not cause falling, and do not typically restrict activities.
They can occur in a variety of ages, and older children may describe a feeling that they must make the movement. Vocal tics include grunting, humming, clicking and sniffling, but rarely formed words.
As pathophysiology, structural and functional neuroimaging studies have shown the involvement of the basal ganglia and related cortico-striato-thalamo-cortical circuits, and the dopaminergic neuronal system.
Differential diagnoses include myoclonic seizures. A change of consciousness, inability to suppress, onset in sleep, and episodes that are rhythmic and repetitive are red flags.
Workup includes a clinical diagnosis, EEG or screening for the presence of ADHD, OCD or other behavioral disorders.
Most children do not need treatment for tics, unless the behavior is disturbing physically or socially. Central alpha agonist medications (Clonodine, Tenex) or dopamine antagonist drugs (Haldol, Risperdal, ORAP, Pimozide) can be useful.
Most children outgrow tics, and up to 15 percent of people diagnosed with Tourette’s outgrow the condition.
Typically shown in early childhood after age 1, these episodes are marked by repetitive stereotyped movements that may or may not be rhythmic. They are self-stimulatory and otherwise without purpose. Examples include hand flapping or rocking. Events may persist into adulthood, especially in patients with autism or an intellectual disability.
These events are behavioral in nature, but a differential diagnosis is automatisms with complex seizures.
Red flags include a change in awareness, which can be difficult to detect in children with autism, and events that are rhythmic and repetitive.
Workup includes and EEG, and treatment is applied behavior analysis or therapy from a psychologist. For children who can be taught not to exhibit the behavior, prognosis is good.
9. Night terrors
These episodes are more common in children around age 3, but can surface earlier and persist into teenaged years and adulthood.
A patient may awake from deep sleep with a terrified look, screaming and showing decreased responsiveness. They may tremble, and episodes may occur several times a night.
Their exact mechanism is unknown, but night terrors may be genetic.
Differential diagnoses include nightmare, seizure, arousal disorder or parasomnia. Episodes are more worrisome if they occur many times a night, include strange repetitive movements like pelvic thrusting or bicycle pedaling motions, or are accompanied by progressive academic or developmental decline.
Workup includes a history and clinical diagnosis, polysomnogram or video EEG sometimes combined with polysomnogram.
Most children grow out of night terrors and do not require treatment, but can benefit from counseling on sleep habits or psychology. Though rarely, medications like clonazepam or amitriptyline can be helpful.
These events are more common in teenaged patients. They include a sudden and brief loss of consciousness typically with associated loss of muscle tone. Patients may fall or slump forward or backward, and have mild twitching. They might also have a light-headed, giddy feeling or blackening of vision.
Loss of consciousness lasts only seconds, and patients may hear people around them before vision returns. They may feel groggy afterward, but not confused.
Recovery is quick, and episodes typically have a trigger: standing up too quickly, standing in place too long with legs locked, dehydration on a hot day, emotional fright, valsalva including defecation or urination, hair traction, or venipuncture.
These episodes are not a primary neurological event, and a common feature is reduced cerebral perfusions. They stimulate the vagus nerve, which causes bradycardia. Decreased venous tone allows venous pooling and decreased blood return to the heart. Valsalva prevents venous return to heart
Differential diagnoses are complex partial or other types of seizures, or postural orthostatic tachycardia syndrome.
Red flags include no provoking factor, prolonged and prominent tonic-clonic movements or hemi-clonic movements, cyanosis, or occurrence in very young children or those with a neurological or developmental disorder.
Workup includes diagnosis based on clinical history; orthostatic blood pressures; EEG if any red flags are present; and KG/Holter study, tilt-table testing, or cardiology consult if the patient’s clinical history is suggestive of dysrhythmia.
Treatment includes counseling on how to avoid symptoms, including standing up slowly, drinking water and avoiding triggers.
Looking forward, a predisposition to fainting may continue into adulthood. The episodes don’t cause neurologic injury, but a patient could get injured from a fall.
11. Cyclic vomiting
These episodes entail one to five days of copious vomiting, followed by asymptomatic periods. The average age of patients is 5, but episodes can span from infancy to adulthood.
They usually start in early morning or late afternoon. Abdominal pain, anorexia, lethargy, pallor, sweating and salivation accompany the episodes.
Triggers include emotional stress, energy-depleting states, some foods and menstrual cycles.
To diagnose, the patient must have stereotypic episodes of vomiting with at least two acute-onset episodes in the past six months, each occurring at least one week apart and persisting for less than one week.
Red flags include periods of unresponsiveness, tonic-clonic movements, visual changes, other neurological symptoms such as hemiparesis, hematemesis and melena.
Workup includes MRI or GI referral and endoscopy.
IV fluids, anti-nausea medication, pain relief medication is common treatment. Periactin; amitriptyline; antiepileptic medications with migraine indications (Depakote, Topamax, others); and propranolol can be used as prophylactics.
When child and adolescent patients complain to their parents about a headache, it can be anything from a plea to stay home from school in hopes of avoiding a test, to a sign of something more serious. Dr. Sharief Taraman, a pediatric neurologist at CHOC Children’s, offers advice to the referring community on acute and chronic headache management in children and teens, including headache hygiene, non-medical intervention options, and referral guidelines.
Types of headaches often seen in children and adolescents
Migraine symptoms in kids
At least 5 attacks that meet the following criteria:
Headache lasting 1 – 72 hours
Headache has at least two of the following features:
Pain on both side or one side of the head
Pain is pulsating
Moderate to severe intensity
Aggravated by routine physical activities
At least one of the following:
Nausea and/or vomiting
Sensitivity to light or noise
Chronic migraines are indicated by 15 headache days per month over a three-month period, and at least half of those are migraines.
About 1 out of every 20 kids, or about 8 million children in the United States, gets migraines. Before age 10, an equal number of boys and girls get migraines. But after age 12, during and after puberty, migraines affect girls three times more often than boys.
Tension headache symptoms in kids
Headache lasting from 30 minutes to seven days
Headache has at least two of the following characteristics:
Pain in two locations
Pressing or tightening feeling (not a pulsing pain)
Mild to moderate intensity
Not aggravated by routine physical activity such as walking or climbing stairs
No nausea or vomiting – many children experience a loss of appetite
Either sensitivity to light or sensitivity to sound
Tension headaches occur most often in children ages 9-12
Cluster headache symptoms in kids
At least five headaches that meet the following criteria:
Severe pain in one location: within the eye, above the eyebrow, or on the forehead, that lasts from 15 minutes to three hours when left untreated
Headache is accompanied by at least one of the following symptoms on the same side of the body as their headache:
Conjunctival injection and/or lacrimation
Nasal congestion and/or excess mucus in the nose
Forehead and facial swelling
Droopy eyelid and/or small pupil
A restlessness or agitation
Cluster headaches usually start in children at around 10 years old
Post traumatic headache symptoms in kids
Acute post traumatic headache: lasts less than three months and caused by a traumatic injury to the head
Persistent post traumatic headache: lasts more than three months and caused by a traumatic injury to the head
Both acute and persistent headaches develop within one week of: the injury to the head, regaining of consciousness following injury to the head, or discontinuing medicine that impairs the ability to sense a headache following a head injury
Extended recovery risk factors:
Prolonged loss of consciousness or amnesia
Initial symptom severity
Premorbid history of ADHD, mood disorders, and migraines
Sleep apnea headache symptoms in kids
Typically a morning headache
Pain is present on both sides of the head
Lasts more than four hours
Not accompanied by nausea, nor sensitivity to light or sound
Medication overuse headache symptoms in kids
Headaches on 15 or more days per month
Takes over-the-counter medication for headaches more than three times per week over a three-month period
Headache has developed or gotten worse during medication overuse
Pattern of headaches resolves or improves within two months after discontinuing the overused medication.
Remind parents of headache hygiene tips
There are a number of things parents can do to prevent headaches, says Dr. Taraman. Remind parents to practice headache hygiene:
A variety of non-medical interventions can be helpful for children who are suffering from headaches, including ice packs; warm baths; taking a nap in a cool, dark room; neck and back massage; and taking a walk.
Medication as treatment for headaches in children
Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen or naproxen, should be limited to no more than three days per week, with no more than two doses per day, in order to avoid medication overuse headaches.
Triptans are often used to treat moderate to severe migraines or cluster headaches, but should not be prescribed to patients with cardiovascular disease, uncontrolled hypertension, basilar migraine or hemiplegic migraine.
Encourage patients to keep a headache diary
Encourage your patients to keep a journal of their headaches so you can identify a pattern. Patients should keep track of:
Headache start date and time
What happened just before the headache?
How much did your head hurt, on a 0-10 pain scale?
Where did your head hurt?
What did you feel just before and during the headache?
What did you do to make yourself feel better?
Did you feel better, on a 0-10 pain scale?
Headache end date and time
When to refer cases of headaches to pediatric neurologists
Dr. Taraman offers the following guidelines on when to refer headaches to a pediatric neurologist for imaging:
Diagnosis of neurofibromatosis of tuberous sclerosis
If the child is awoken on a regular basis by headache pain or vomiting
Headaches beginning shortly after arising from bed in the morning (i.e., positional headache)
Chronic progressive headaches
Persistently posterior headaches
Chronic headaches in patients less than 3-5 years old
When patients have a history of the following symptoms during headaches, Dr. Taraman offers the following guidelines on when to refer headaches for imaging and possible neurology consultation:
While most medical providers are familiar with Return to Play laws – a step-wise progression addressing when student athletes with concussions should return to sports/physical activity – there is no similar legal process for “Return to Learn” guidelines addressing when students with concussions should return to school.
Further, a study in the December 2016 Pediatrics found that only a few states have Return to Learn concussion laws, and these varied in delineation of responsibility. Some of the laws were restricted to student athletes, excluding students who sustained non-sport related concussions.
When returning a student to the classroom after a concussion, we try to balance stimulation levels and worsening of symptoms, explains Dr. Chris Koutures, a board certified pediatrician and sports medicine specialist at CHOC Children’s. While too much cognitive exertion can lead to headaches, problems concentrating, fatigue and trouble with emotional control, over restriction from classroom and academic activities can result in social isolation and anxiety about falling behind or lower grades that can also slow the recovery process.
“Returning to the classroom after a concussion optimally takes a team approach including the student, family, medical and education teams,” Dr. Koutures says. “Flexibility and creativity in paying attention to individual student needs and concerns can make this process more rewarding for all parties.”
Dr. Koutures advises the patient’s care team to follow CHOC’s recommended six stages for returning a student to school after a concussion, including the following added guidelines:
Step-wise Return to Learn Progression
Step 1: No formal academic activity
Recent studies suggest that full or prolonged limitations in cognitive activity may actually delay recovery
In first few days after concussion, allow 15-20 minute intervals of single-task activities that do not provoke symptoms and are not excessively taxing
Listen to light music
Draw or color
Passive television or movies (at home), larger screen preferred, lower volume
Some texting, smartphone use; want to balance maintaining key social contacts with not having symptom-flare
Conversations with 1-2 other people
Separate the 15-20 minute bursts of activity by 30-40 minutes minimum of non-cognitive activity
If symptoms flare before 15-20 minute limit, stop activity and try again later
If patient can handle 2-3 periods of 15-20 minute activity over the course of day, can consider advancing toward partial return to school
Step 2: Light academic activity
Attend 1-2 periods or 1-2 hours of school
Select consecutive classes; have child help make decision
No physical education or other activity classes
Caution with more noisy classes such as woodshop, music/band, chorus
Tend to avoid first class in morning to allow more sleep and arrival at school without busy parking lot and hallways
Main goal: be in class; no responsibility for note-taking, participating in class /responding to teacher, in-class work, homework or testing
Audible learning (most kids handle this better than visual learning after a concussion)
Should have pre-printed notes for reference or have others take notes and share
Sit away from louder students, windows, projectors, or other light/noise stimulation
Sit close to teacher
Allow to wear earplugs and sunglasses as needed
May allow brief 1-2 minute periods of putting head on desk for rest
May leave class early to avoid the noise and commotion of hallways during passing periods
Step 3: Increased academic activity
Expand day to 3-4 periods or hours per day
Incorporate break periods (nutrition break, lunch)
Have quiet place to rest
Recommend against assemblies or rallies due to noise stimulation
Continue to avoid physical education or activity classes
Main goal is to be in class and handle longer day; still not responsible for note-taking, participating in class/responding to teacher, in-class work or homework
Step 4: Full-time attendance
Full-day attendance without activity or other higher-stimulation classes
May expect some increased fatigue at end of school day
If student wants to nap after school, limit to no more than one hour
May start to take own notes, though helpful to have pre-printed teacher’s notes or other student notes
Incorporate “to do” lists with short-block (10-15 minute) work periods followed by short (5 minute) breaks
Break period and breaks in class (especially if block schedule) may still be needed
If possible, move most challenging courses to time of day when student feels the best
Step 5: Return to Majority of Academic Activities
Once handling full day attendance, can resume taking notes in class, verbal responses to teacher, and in-class work
May begin homework starting with limits to 30-60 minutes a night and priority on essential concepts that are needed for eventual testing or continuity of learning
Waive any projects, papers, essays or other assignments that are not required for future learning needs
Try to limit burden of make-up work; focus should be on those assignments that are necessary for future learning
Sequential classes (math, foreign languages, science) tend to be the most challenging for make-up work
No tests or quizzes at this stage
Audible learning – listen/speak responses vs. writing, dictating work, audiobooks may be more favorable at this point
Step 6: Return to Full Academic Activity
Full-day attendance without symptoms, fulfilling all in-class duties and completing usual homework assignments
Can resume tests and quizzes
Strongly consider waiving missed tests or quizzes
Combine missed tests or quizzes to allow more quick completion of make-up work
Allow student to take missed tests/quizzes to gain exposure/mastery of material without being graded, or only receive grade if results are in usual level of achievement
Assign grades at end of grading period based on level of work prior to concussion
May need more time for test completion
May need individual room placement for testing
May limit testing/make-up testing to one test per day
May allow open book, use of notes, word banks or home-based testing
Consider alternate forms of testing such as spoken test, or multiple choice vs. longer essay responses that might be more taxing for the student
Students may still benefit from more audio learning
Can resume physical education (with physician release) and activity courses.
To contact Dr. Chris Koutures, please call 714-974-2220.