Development Board Review Questions
Angkana and Gunjan's Development Board Review 2. A 15-month-old girl is brought to you for a health supervision visit. She has a sibling who has mental retardation. Her parents would like to know if this child has intellectual impairment. Of the following, your BEST next step in evaluation is to A. ask about her language skills B. evaluate her motor development C. look for evidence of stranger anxiety D. observe her interaction with her parents for bonding and attachment E. plot her growth and evaluate her nutritional status.
3. You are seeing a 9-month-old girl for her health supervision visit. She recently started saying "dada" and "mama" nonspecifically, and she imitates sounds. She rolls but does not sit. She picks up a small raisin with an immature grasp, and she cries briefly when you take her from her mother. Of the following, you MOST appropriate statement to the parents is that A. her development is appropriate for her age B. She has a delay in her fine motor skills C. She has a delay in her gross motor skills D. She has a delay in her language skills E. She has a delay in her social skills 4. You are evaluating a 10-year-old boy who has received a previous diagnosis of mental retardation. Growth parameters are as follows: height 25th %, weight 50th %, and head circumference 50th%. Results of a physical exam are normal, and he is not dysmorphic. A comprehensive evaluation by a geneticist failed to reveal a cause for his mental retardation. he if functioning at the 5- to 6-year old level. His mother states that he required resuscitation at delivery. His Apgars were 3, 6, and 8 at 1, 5, and 10 minutes. He was evaluated in the normal newborn nursery and went home at 2 days of age. She would like to know whether his delivery caused his mental retardation. Of the following, your BEST response is: A. A cause commonly is identified in children who have mild MR B. He does not have MR C. He should be referred for specific neuropsychological testing D. it is unlikely that the delivery is the cause of the MR E. she should talk to the delivering physician
ANSWERS 1. ANSWER BNewborns can fixate and respond to changes in illumination. A newborn's visual acuity is approximately 20/400. Visual acuity improves over time, with normal developmental changes in the cornea, lens, and fundus. A 2-year-old has visual acuity of approximately 20/60, and a child will have 20/20 vision between 7 and 9 years of age. Newborn eye examination includes external assessment of the eyelids to evaluate for inadequate opening or closure of the eye, corneal transparency, or asymmetric globe shape and size. Direct ophthalmoscopic examination is used to evaluate for the presence and symmetry of the red reflex. During the first 2 weeks after birth, an infant will fixate on a parent's face, especially when the face is in the infant's best focal length of 8-15 inches. At 1 month of age, an infant will briefly track a face horizontally. At 2 months of age, an infant will track a ring horizontally and vertically, and at 3 months, he or she will track a ring circularly. The infant in the vignette shows evidence of abnormal vision and should be referred expeditiously to an ophthalmologist for further evaluation. Compared with healthy infants, who can fixate in the first few weeks after birth, this infant shows marked visual delay. Similarly, the infant's lack of response to visual stimuli, which typically is apparent very early in life, suggests abnormal visual development. Increased visual stimulation will not improve the child's vision. 2. ANSWER: A Language and problem-solving skills are the best predictors of intelligence in young children. A 1-year-old should have receptive language skills that include being able to look for a named family member (11-month skill) and following a command with a gesture (12-month skill). Expressive language skills include appropriate use of "mama" and "dada" (10 months), first word and imitative sounds (11 months), and immature jargon or sentence-like intonation with the ability to point to wants (12 months). If language evaluation is possible, this provides the best estimate of cognitive ability. However, problem-solving abilities may also be used to evaluate cognitive function and may reflect cognitive ability more accurately in children who have hearing impairment or oral-motor dysfunction. A 1-year-old should be able to place a cube in a cup and look at pictures in a book (10 months), uncover a toy under a cup (11 months), and cooperate with dressing (12 months). Although motor development may act as a marker for other delays, motor skills do not correlate with cognitive function. Social milestones of bonding (1 to 3 months), attachment (3 to 6 months), and stranger anxiety (6 to 10 months) are more variable than motor and cognitive domains. Nutritional status may contribute to normal growth, health, and well-being, but growth is not predictive of cognition. 3. ANSWER: C The girl described in the vignette rolls, but does not sit, which indicates delayed gross motor skills for a 9-month-old. Most infants begin to roll prone to supine at 4 months, supine to prone at 5 months, and sit when propped at 5 months. They sit unsupported at 7 months and come to a sitting position and pull to a standing position at 8 months. At 9 months they begin to cruise. The 9-month-old girl in the vignette has the gross motor skills of a 4- to 5- month-old and shows a 50% gross motor delay. Saying "mama" and "dada" non-specifically and imitating sounds are 8 month language skills. The girl in the vignette should also be able to play gesture games (9 months) and soon should be able to use "mama" and "dada" appropriately (10 months). The ability to pick up a small raisin with an immature pincer grasp by using a scissoring motion with her thumb and forefinger is an appropriate fine motor skill for her age. She should also be able to finger feed (9 months) and have a mature pincer grasp with the tips of her thumb and forefinger at 10 months. Becoming concerned and crying when she is taken away from her mother (stranger anxiety) is appropriate for her age. Infants often demonstrate aversion to strangers at 6 months, but they commonly show more profound reaction to strangers at 8-9 months of age. Infants at this age begin to identify caretakers as "permanent." At 10 months, most infants begin to develop object permanence and will search for an object that is dropped out of sight. 4. ANSWER: D Mental Retardation (MR) occurs in 2-3% of the population. There are 3diagnostic criteria for MR. First, the individual must have an IQ of70 or below, as measured by an age-appropriate individually administered IQ test. Second, he or she must have deficits in adaptive functioning in at least 2 of the following areas: communication, self-care, home living, ocial/interpersonal skills, use of community resources, self-direction, functional academic skills, work, leisure, health, and safety. Third, the onset of symptoms must be before 18 years of age. A definite or probable cause can be identified in approx 25% of children who have MR. A cause is more likely to be found in children with severe-to-profound MR than in children with mild MR. The normal range of IQ is commonly defined as 2 standard deviations above and below the mean, with a mean IQ being 100. Degrees of MR and corresponding IQ scores are: mild, 70-55; moderate, 55-40; severe 40-25; and profound, less than 25. The child in the vignette has been diagnosed as having MR, which appears to be an accurate diagnosis based on his reported functioning at the 6-year-old level. A child's IQ may be estimated by dividing the developmental age by the chronological age and multiplying by 100. Although results of a formal IQ test are not reported, it is likely that the child has an IQ of approx 60 (6 years [developmental age]/10 years [chronological age] x 100). His level of functioning reflects mild-to-moderate mental retardation. Further neuropsychological testing may provide educational and vocational assistance, but it is unlikely to assist in diagnosing the cause. Although initial Apgar scores were low for this boy, his newborn stay was uncomplicated, and results of his physical exam at 10 years are normal. There is no history of the most common perinatal causes of MR: asphyxia, metabolic disorder hypoglycemia, hyperbilirubinemia), infection, or intracranial hemorrhage. Low Apgar scores associated with an otherwise normal newborn course do not reflect birth injury, such as asphyxia. Infants who suffer asphyxia have multiorgan involvement and are acutely ill in the newborn period. Accordingly, it is unlikely that the delivery is the cause of the boy's MR. |