Pediatric Examination and Board Review (47 page)

A 36-month-old boy named Max with developmental delay presents for a 3-year-old physical examination. His mother, Madeleine, is 28 years old. The family has just moved into this area. She reports that Max sat at 9 months and walked at 18 months. He can walk up and down steps, and he kicks and throws a ball. A psychologist’s examination indicated that Max can build a tower of 8 blocks, string 4 beads, and scribble on paper with crayons. He can draw a vertical line but fails to copy a circle. Max began saying single words at 2 years but still has significant immature jargon use and has not yet combined two words into phrases. Max can identify three body parts, point to familiar objects in books (cat, ball, car), and follow simple commands such as “sit down,” “get the doll,” and “come here.” He likes to roll a ball back and forth with his dad, can remove all his clothes, tries to imitate what adults do in chores, and is not toilet trained. The psychologist who evaluated Max 3 months ago told the mother his IQ equivalent was 72 plus or minus 5.

SELECT THE ONE BEST ANSWER

1.
The developmental areas most delayed for Max are

(A) motor

(B) speech

(C) language and development

(D) social-emotional

(E) A and D

2.
Max’s developmental skills are like those of a

(A) 12-month-old

(B) 18-month-old

(C) 24-month-old

(D) 27-month-old

(E) 30-month-old

3.
If a child has a preschool IQ of 67, what will he be like at age 7?

(A) unable to talk in sentences

(B) in diapers

(C) not able to count

(D) just starting school because he was too slow at ages 5-6

(E) attending second grade in his community with special education and resource supports

4.
Children with mild mental retardation

(A) have an IQ score more than 2 standard deviations below the mean

(B) do not have adaptive delays

(C) cannot learn to read

(D) cannot participate in mainstream education

(E) are ineligible for Special Olympics

5.
Children with severe language disorders (standard scores <60, normal 100 ± 15)

(A) never learn to speak in sentences

(B) cannot learn to read

(C) never have attention deficit hyperactivity disorder (ADHD)

(D) may have 10-point IQ changes if language skills increase

(E) A and B

6.
Children with classical autism

(A) do not walk until age 4

(B) cannot learn any self-care skills

(C) have difficulty communicating in sentences and carrying on a conversation

(D) always have challenging behavior

(E) have excellent joint attention at age 12 months

7.
The goals of Early Intervention for children with preschool developmental and language delay include all of the following except

(A) family supports

(B) promotion of communication skills

(C) prevention of cognitive decline

(D) promotion of self-care and social skills

(E) A and D

8.
At age 11, Max’s mother brings his previous school evaluations

Psychological: At the age of 6 years, 2 months, he was administered the Stanford-Binet Intelligence Scale. The test resulted in a mental age of 4 years, 8 months, equivalent to an IQ of 75.

Speech-Language: At the age of 7 years, 10 months, he was evaluated for speech and language. Mildly to moderately delayed articulation skills at an approximate 4-year mental age were revealed. His receptive skills were at a 5-year mental age. At the same time, his hearing was evaluated and the results indicated that his hearing was normal bilaterally.

Medical History: His history reveals no evidence of seizures, convulsions, or other significant illnesses. His vision is normal. His physical growth has kept him above the 95th percentile.

Academic Functioning: At the age of 7 years, 8 months, he was evaluated in school, where he had been placed in a special education class for children with academic difficulties. His teacher reported that he interacted well with peers, evidenced by his ability to share and work in groups. He could count to 50 but had difficulty remembering sounds associated with letters. In reading, it was reported that he could recognize 15 letters of the alphabet. An assessment of his handwriting skills stated that he could print his first name neatly.

Social History: Max lives with both natural parents and two brothers, age 6 and 8, both of whom have normal intellectual capabilities. His father is employed as a maintenance worker with the highway commission. His mother is not employed outside the home.

What is Max’s developmental diagnosis?

(A) slow learner with borderline intelligence

(B) attention deficit disorder

(C) mild mental retardation

(D) learning disabilities

(E) moderate mental retardation

9.
If, at the age of 10, Max reads at a third-grade level, what is his capability for becoming literate (fifthgrade reading level)?

(A) 0%

(B) 50%

(C) 90%

(D) 100%

(E) there is no way to predict

Questions 10 through 29: Young adult prognoses. Use the following probabilities to indicate the degree to which Max will be able to perform the skills listed below when he matures into adulthood.

(A) less than 10%

(B) 25%

(C) 50%

(D) 90%

(E) 100%

10.
Enter into a marriage contract

11.
Cook a meal unsupervised

12.
Raise children

13.
Use a lock and key

14.
Indicate symptoms verbally to a physician

15.
Budget for monthly expenses

16.
Do own laundry

17.
Make change for a dollar

18.
Tell time

19.
Have an intimate sexual relationship

20.
Fill out a job application

21.
Use public transportation independently

22.
Recognize traffic and exit signs

23.
Schedule daily activities independently

24.
Use a pay telephone

25.
Choose appropriate clothes to wear

26.
Follow a national news event

27.
Act appropriately toward strangers

28.
Sustain a friendship with another person

29.
Anticipate hazards appropriately

30.
Vocational Placement: By adulthood, where would Max most likely work?

(A) in skilled, competitive employment

(B) in unskilled, competitive employment

(C) in supervised, full-time employment

(D) in supervised, part-time employment

(E) he would be incapable of any productive employment

ANSWERS

1.
(C)
Max presented with motor delay followed by challenges in language understanding and use as well as delays in problem-solving and adaptive skills. Children with preschool global developmental delay have standard scores of 2 standard deviations below the mean in two or more areas. They also have delays in communication skills.

2.
(C)
Twenty-four-month-olds can string beads, imitate strokes, and know body parts.

3.
(E)
Children with mild mental retardation are toilet trained, talk in sentences, and can count at age 7. All children, whatever the severity of their developmental delays, can attend school from ages 3-21. Max will be attending second grade, but he will require supports.

4.
(A)
Children with mild mental retardation have IQ scores 2 standard deviations below the mean, with concurrent adaptive delays. They learn to read, and they can participate in both mainstream education services and Special Olympics.

5.
(D)
Children with severe language disorder can learn to talk in sentences. They also may learn to read. They can have ADHD. Because IQ tests are strongly verbally mediated, as children’s language output improves, their IQ may rise.

6.
(C)
Children with autism may walk on time but struggle with joint attention. They learn self-care. They may not have severe behavior challenges (aggression, self-injuries). They do have difficulty with language pragmatics (ie, carrying on conversations appropriately).

7.
(C)
The goals of Early Intervention are to provide quality early child educational experiences that emphasize learning through play, opportunities that promote self-care and adaptive skills, modeling of social skills (circle time, sharing, listening in groups), and promoting communication skills (modeling activities with words, songs, rhymes).

8.
(A)
A child who was previously tested with an IQ of 75 does not have mild mental retardation (IQ 55-69) or moderate mental retardation (IQ 40-54). He is making progress and does not have a discrepancy between his cognitive, communicative, perceptual, and academic skill areas that are part of the federal definition for learning disability. His teacher and parents have not endorsed classroom or home difficulty with inattention, impulsivity, or motor hyperactivity, thus ruling out an attention deficit disorder. Max’s developmental diagnosis is “slow learner with borderline intelligence (IQ 70-84).”

9.
(C)
When Max was tested by a school psychologist in first grade, he had below-average intelligence. Subsequent testing revealed both an articulation disorder and difficulty with complex language skills. Many schools using antiquated discrepancy formulas will treat a child with an IQ of 75 as one who cannot achieve basic functional literacy of grade 5 reading skills. Although language-related skills are a challenge for Max, the ability to read out loud and comprehend third-grade material when he is 10 suggests a high probability for basic literacy.

10.
(C)
50% can enter into a marriage contract

11.
(E)
100% can cook a meal unsupervised

12.
(C)
50% can raise children

13.
(D)
90% can use a lock and key

14.
(E)
100% can indicate symptoms verbally to a physician

15.
(D)
90% can budget for monthly expenses

16.
(E)
100% can do his own laundry

17.
(E)
100% can make change for a dollar

18.
(E)
100% can tell time

19.
(E)
100% can have an intimate sexual relationship

20.
(E)
100% can fill out a job application

21.
(E)
100% can use public transportation independently

22.
(E)
100% can recognize traffic and exit signs