Pediatric Examination and Board Review (54 page)

1.
What developmental screening tests are not indicated before kindergarten entry?

(A) vision

(B) hearing

(C) draw a person

(D) DDST-2

(E) timed running

2.
What developmental assessment for children with concerns about kindergarten might be used by a pediatrician?

(A) Capute Scales

(B) Brigance Diagnostic Inventory of Early Development

(C) Pediatric Evaluation of Developmental Skills (PEDS)

(D) Bayley Scales

(E) Kaufman Scales of Early Learning Skills

3.
All of the following behavior inventories are helpful for 7-year-olds with concerns about attention and learning at school except

(A) Vanderbilt Behavioral Rating Scales

(B) Child Behavior Checklist (CBCL)

(C) Connors Rating Scales

(D) tests of attachment

(E) no exceptions; all of the above are helpful

4.
Which of the following are the most important signs that Arnold may have a learning disability?

(A) the teacher’s concerns about behavior

(B) the discrepancy between IQ and achievement

(C) his difficulty in learning to read in the first grade

(D) a family history of reading difficulty

(E) C and D

5.
Which of the following interventions is/are helpful for children with learning disabilities?

(A) repeating grades

(B) phonologic awareness training

(C) avoiding talking books

(D) optometric training

(E) A and D

6.
After your initial discussion with Arnold’s mother, history, and general physical examination, Arnold returns for an additional half hour. During this time, which of the following developmental and functional areas related to school achievement is least helpful in your evaluation?

(A) auditory memory skills

(B) visual perceptual skills

(C) developmental coordination skills

(D) oral reading

(E) reading comprehension

7.
The mother says she believes sugar and food additives are causing his problem. What would be least helpful?

(A) referral to CHADD (Children and Adults with Hyperactivity and Attention Deficit Disorder)

(B) decreased intake of sugar-containing beverages

(C) consultation with an endocrinologist

(D) replacing junk food with more healthful snacks

(E) educational materials for parents

8.
Arnold’s mother says his teacher has suggested that medication might help his activity level. What medication or type of medication might you first consider for Arnold?

(A) diphenhydramine

(B) stimulants

(C) clonidine

(D) lorazepam

(E) hydroxyzine

9.
All but which one of the following can enhance objectivity during a trial of stimulants?

(A) choose target behaviors

(B) tell the school you are putting him on natural vitamins

(C) educate the mother about ADHD goals and side effects

(D) ask the mother to record weekly ratings

(E) ask the teacher to record weekly ratings

10.
Which of the following statements about stimulants is true?

(A) they work in 80% of children with ADHD

(B) they are addictive

(C) they cause tics

(D) they should always be stopped on weekends and holidays

(E) they can all be crushed and sprinkled on apple sauce

11.
Which of the following conditions promote(s) longterm success in children with learning and attention disorders?

(A) avoiding extracurricular activities

(B) positive experiences in community-based activities, such as scouts, sports, and religiousrelated after-school activities

(C) having peers as friends who engage in highrisk behaviors

(D) family disagreement on the value of education

(E) none of the above promotes long-term success

ANSWERS

1.
(E)
Vision, hearing, perceptual, and developmental screening tests are indicated. Timed running is indicated for high school students on the track team.

2.
(C)
The Capute Scales assess language and problem-solving skills in children ages 0-3 years. Special training and testing materials used by psychologists are required for the Brigance, Bayley, and Kaufman tests. The PEDS can be used by pediatricians as a query for parents for their children’s developmental and behavioral concerns.

3.
(D)
Connors and Vanderbilt behavior scales, as well as the Child Behavior Checklist, are appropriate behavior rating instruments. Tests of attachment are not indicated.

4.
(E)
Of the choices listed, the patient’s difficulty in learning to read in the first grade and the family history of reading difficulties should most raise the index of suspicion for a learning disability. The teacher’s concern about behavior needs to be coupled with what the child is learning at school. Although many states require that there be a gap between IQ and achievement for the diagnosis of learning disability, recent research indicates that this criterion does not have adequate sensitivity and specificity.

5.
(B)
Phonologic awareness training, which involves learning the sounds associated with letters, is the key to learning to read. Repeating grades and optometric training have not been helpful. Talking books are important resources to help facilitate accommodations. Talking books do not interfere with learning to read.

6.
(C)
Developmental coordination skills are not as important as memory, perceptual, and reading skills in assessing school achievement.

7.
(C)
Consultation with an endocrinologist is not indicated. There have been several reviews including randomized controlled studies that do not support the notion that sugar is responsible for the behavior of patients with ADHD. All children and adults benefit from restricted access to sugarcontaining beverages and high caloric density (junk) foods. Provision of written materials as well as referral to the organization for CHADD would be helpful.

8.
(B)
Arnold has ADHD and dyslexia. Key indicators are difficulties putting sequences together, difficulties mastering phonologic skills, and difficulties with activity level and attention. He would benefit from a biopsychological strategy emphasizing behavior management, stimulants, and quality academic supports. Stimulant medications, methylphenidate, dextroamphetamine, and others, are the first-line agents in conjunction with educational accommodations, behavioral supports, and family supports. Diphenhydramine, lorazepam, and hydroxyzine are not indicated. Clonidine is a second-line agent.

9.
(B)
Telling the school that Arnold is on vitamin therapy is not helpful. Choosing target behaviors of impulsivity, attention, and hyperactivity is helpful. Initially educating the mother about ADHD goals and side effects is critical as well as subsequently demythologizing the disorder for the child. Feedback from both parent and teacher and self-report from older children is also useful in ongoing management and in titrating the medication.

10.
(A)
Stimulants work in 80% of children with ADHD. They are not addictive. They decrease the risk of substance misuse when properly used. They do not cause tics. One cannot crush all delivery systems. Most children benefit by staying on them on weekends and holidays because ADHD is an ongoing, not intermittent, disorder.

11.
(B)
Community successes enhance self-confidence in children with ADHD. These include sports, scouts, church, music, and clubs. Having friends who are appropriately grounded is critical. Family consensus and problem-solving communication is important to ongoing management.

S
UGGESTED
R
EADING

Aylward G. Additional considerations. In: Aylward GP, ed.
Practitioner’s Guide to Developmental and Psychological Testing
. New York, NY: Plenum Medical; 1994:221-232.

Marks KP, Glascol FP. Developmental and academic surveillance and screening. In: Augustyn M, Zuckerman B, Caronna EB, eds.
Development and Behavioral Pediatrics: A Handbook for Primary Care
. Philadelphia, PA: Lippincott Williams & Wilkins; 2011:48-55.

Ramey CT, Ramey SL. Early intervention: optimizing development of children with disabilities and risk conditions. In: Wolraich ML, ed.
Disorders of Development and Learning.
3rd ed. Hamilton, Ontario, Canada: BC Decker; 2003:89-104.

CASE 33: AN 18-MONTH-OLD BOY WHO HAS NOT SPOKEN