Pediatric Examination and Board Review (51 page)

David was born prematurely at 32 weeks’ gestation with a birthweight of 1800 g. Apgar scores were 3 and 7. David’s mother and father did not finish high school.

SELECT THE ONE BEST ANSWER

1.
David may not go to kindergarten if

(A) his parents elect not to send him

(B) he cannot talk clearly

(C) he walks down steps, 2 feet on each

(D) he occasionally needs to be reminded to use the bathroom

(E) he is considered immature

2.
Developmental disorders common after prematurity include all the following except

(A) perceptual delays

(B) language delays

(C) learning disabilities

(D) attention deficit disorder

(E) autistic spectrum disorder

3.
The least common reason for a child to repeat kindergarten is

(A) developmental delay

(B) ADHD, inattentive type, in a girl

(C) treatment for lead poisoning

(D) parent with difficulty learning to read

(E) frequent tardiness or absences because of asthma

4.
Major reasons boys have difficulty in reading are

(A) high rates of mental retardation

(B) high rates of language, learning, and attention difficulties

(C) they like sports

(D) they misbehave and get into fights

(E) A, B, and D

5.
David’s grandmother has wondered whether David might have ADHD or be mildly retarded like her brother who also was premature. Additional family pedigree history concerning learning, behavioral, and school performance of the following individuals will all be helpful except information about David’s

(A) parents

(B) uncles and aunts

(C) grandparents

(D) adopted cousin

(E) all of the above (none of the information will be helpful)

6.
David has an uncle and two cousins who experienced delayed language development. Your developmental assessment finds that David runs clumsily, does not describe what he would do if he were tired or thirsty, has speech that is understandable to you 50% of the time, pedals a tricycle, balances briefly on one foot, follows 2-step directions quickly but needs to have the second step repeated, knows three of five colors, counts to 5, makes some mistakes when reciting the alphabet, and can draw a picture of a boy that includes a head and legs but not face, trunk, or arms. David feeds himself independently, needs assistance with zippers, and reminders to use the bathroom. Based on this information, what is most likely David’s type of developmental disorder?

(A) mental retardation

(B) CP

(C) severe hearing loss

(D) oppositional defiant disorder (ODD)

(E) developmental language disorder

7.
During his kindergarten year David is considered very active and unable to sit still. His parents report that his favorite activities are to watch cartoons and play video games. Components of your initial assessment might include all of the following except

(A) having his mother fill out a behavioral rating scale for attention deficit, hyperactivity, and conduct

(B) having his classroom teacher fill out a rating scale for attention deficit, hyperactivity, and conduct

(C) having the parents read a brochure about attention and learning problems

(D) ordering an EEG to rule out a seizure disorder

(E) having his full-time babysitter fill out a behavioral rating scale for attention deficit, hyperactivity, and conduct

8.
Both his mother and classroom teacher endorse that David is hyperactive and oppositional, which is systematically impacting his classroom and home successes. Management options now include all of the following except

(A) trial of stimulant medications

(B) 504 school plan for behavior supports

(C) teacher instituting an appropriate behavior management plan

(D) expulsion from school until he can control his behaviors

(E) all of the above are good management options

9.
David is better able to sit still and pay attention, but he continues to have difficulties on the playground and gets into frequent fights. The school requests that the family discuss with you whether a different medicine should be used. Important information to obtain includes which of the following?

(A) frequency of fights

(B) presence of aggression toward parents

(C) presence of aggression toward brother

(D) David’s description of the events

(E) all of the above

10.
David states that he gets into fights with only one other child on the playground. That child is considered a bully by several other classmates. David has several friends in the neighborhood, attends church regularly, and sings in the choir. He is kind to the dog. He has never been accused of stealing. Indicators of conduct disorder include all of the following except

(A) lying

(B) stealing

(C) having a sense of remorse

(D) torturing animals

(E) A and B

11.
David struggles with learning sounds associated with letters and recognizing words. At the end of first grade, his teacher says he is a nonreader and cannot learn in the regular classroom. You should do all of the following except

(A) insist on a psychoeducational assessment of strengths, difficulties, and academic achievement

(B) agree to repeating a grade

(C) observe David’s attempt to read a picture book

(D) make sure tutoring supports are implemented at school and home

(E) B and D

ANSWERS

1.
(A)
Developmental delays in speech, motor coordination, toileting accidents, or immaturity are not reasons to delay kindergarten. Schools must accommodate children with these impairments both through individual educational support and accommodations, such as an aide, reminders, and more time. In many states it is not mandatory to attend kindergarten. Both speech therapy and developmental support will help promote speech intelligibility and developmental maturity. Unless quality, comprehensive, affordable day care is available, it is better not to wait another year without some focused developmental interventions.

2.
(E)
Approximately 50% of survivors of preterm birth have minor neurodevelopmental impairments, including perceptual, language, learning, and attention disorders. These disorders are more common than CP and warrant both surveillance and proactive management by pediatricians. Autistic spectrum disorders have not been associated with prematurity unless there has been a congenital malformation (eg, Charge, Moebius), congenital infection (eg, rubella), or severe retinopathy of prematurity (ROP) with unfavorable visual outcome.

3.
(B)
ADHD, inattentive type, often presents after age 8 years and thus is not a reason for repeating kindergarten. Developmental delays are often inappropriately managed by grade repetition instead of receiving a comprehensive assessment and appropriate management plan. Children with high lead levels may have both developmental delay and ADHD. These should be managed with appropriate educational supports and interventions to lower the lead level and prevent reexposure. Children whose parents have had difficulty learning to read require appropriate in-school and after-school supports for reading. In addition, adult literacy support can help both parent and child. An asthma action plan should have as its goals control of nocturnal symptoms, including those that disrupt sleep, and a school-based management plan that does not lead to loss of classroom time.

4.
(E)
Males have higher rates of mild mental retardation and higher rates of language, attentional, and behavioral difficulties. Some of this is because of X-linked vulnerabilities. Some is because more disruptive behaviors result in suspension and loss of classroom time. Some is also a result of having ADHD with comorbidities in language processing and executive functioning skills helpful for school success. Recent data, however, suggest that children with early identified reading disorders can be helped with interventions that enhance phonological awareness.

5.
(D)
If immediate family members have not completed high school, this increases David’s risk for not having academic success. Maternal education is strongly correlated with educational success. If there is a pattern of male educational underachievement, then aggressive early learning strategies are required. Information about David’s adopted cousin will not aid in understanding David’s genetic and multifactorial risk for educational underachievement.

6.
(E)
David has some mild delays in language, coordination, and sequencing. He is at risk for learning disabilities and ADHD. David does not have CP because he is running and pedaling a trike. He does not have mental retardation because his core developmental skills suggest that he is functioning at a 3.5- to 4-year old developmental level. David’s language performance does not suggest a severe hearing loss (>70 db), but audiologic assessment is required to rule out a mild to moderate loss. David’s behaviors are active not oppositional. His rate of language performance is consistent with a developmental language disorder.

7.
(D)
EEGs are not routinely indicated for children with ADHD. Children with staring spells, automatisms, and a family history of absence seizures are at increased risk for petit mal seizures. In children not sitting still, both parents and teachers should provide the physician with behavioral ratings for attention deficit, hyperactivity, conduct, and learning. More than one caregiver (teacher for school, after-care adults for after school) should give feedback using an instrument like the Vanderbilt or Connor Scales.

8.
(D)
Children with ADHD and behavioral challenges require a behavioral management strategy for difficult behaviors. Both his mother and classroom teacher provide evidence that David is hyperactive and oppositional, which is systematically impacting his classroom and home successes. Management options for children with ADHD and ODD include a combination of stimulant medication, behavioral management plan at school and at home, and a 504 plan for appropriate accommodation of David’s impulsive behavior. These should be proactively implemented and if there continue to be concerns, both an Individualized Education Program (IEP) intervention and counseling interventions are required. David can be expelled from school if he brings a weapon or sells drugs. Pushing, shoving, noncompliance, and mouthing off are not indications for expulsion.

9.
(E)
Aggression at frequent intervals and toward multiple parties with no sense of remorse indicates a need for more sophisticated management strategies than expulsion. David is better able to sit still and pay attention, but he continues to have difficulties on the playground and gets into frequent fights. Hearing David’s description of the events, explicitly probing the presence of bullying at home and at school, and determining behavioral contracting that leads to performance of school work but loss of privileges is required. Stimulant medications should continue to be used but not expected to cure David of all behavioral problems.

10.
(C)
Children with conduct disorders break rules in multiple settings, including lying, stealing, and mistreating animals. They often do not have a sense of remorse. David’s history is not consistent with conduct disorders but is consistent with ADHD and being bullied. Specific schoolwide interventions on the playground, bus, cafeteria, and gym need to be implemented as well as a mechanism to ensure David’s safety.