Initial Neurodevelopmental Evaluation:
Age: 4 years, 6 months
Reason for Referral: Developmental delays, hand flapping, not interacting well
Kira attends a preschool program at a daycare center. The daycare staff report that she does not initiate play, does not interact with other children or adults, does not listen and does not follow directions. They have also noted that she gets easily distracted, talks to herself, flaps her arms and is not functioning well enough to be in a group of 25 children. Mrs. Baker has observed all of these behaviors at home as well. However, she feels that Kira interacts very well with her and her husband and also with other people once she gets to know them well. She finds her too distractible, stubborn and shy. Kira is very affectionate with her mother and looks to her for comfort and security. Mrs. Baker feels that Kira’s social skills have improved over the past year but not to the point where she can function in a regular Kindergarten.
Kira has mild developmental delays for which she was evaluated by Project Child. At that time, hearing and vision were found to be normal. An occupational therapy evaluation revealed some delays in perceptual fine motor abilities. Occupational therapy was recommended.
Kira is the older of two children to her parents. This was the first pregnancy for Mrs. Baker who was in good health prior to and during the pregnancy. She had onset of premature labor at 28 weeks and was hospitalized for a week. She was placed on Ritodrine and magnesium sulfate. She had a non-stress test every week and was then placed on oral Ritodrine. She also had decreased amniotic fluid. Kira was born at 37 1/2 weeks gestation by cesarean section due to breech presentation. Birth weight was 6 lbs, 6 1/2 oz. Apgar scores were 8 probably at the first minute. No resuscitation was required. At birth she was noted to have congenital torticollis which resolved following some physical therapy. She did get evaluated at the Children’s Hospital of Philadelphia for the torticollis. X-rays of the cervical spine were done, which were normal.
Kira was breast fed. There were no feeding difficulties. She was not a colicky infant. Mrs. Baker recalls that she was never really a good sleeper.
Gross motor delays were noted early on. She did not lift her head up until 4 months of age. She rolled over at 5 months, sat alone at 8 months and crawled at 10 1/2 months. She walked alone at 11 1/2 months. She started riding a tricycle at 3 years. Initially she was clumsy and would trip frequently but this is much less now.
Her language milestones were achieved early. By her first birthday she was saying 5-10 words. By 15 months she had a vocabulary of 15-20 words. Before her second birthday she was speaking in short sentences. She can narrate a story. She conducts a conversation, at least with her mother. She does not have any nonsense words. She does not speak out of context. There is no history of echolalia.
Her fine motor skills have been of some concern. She is a little sloppy when it comes to handling a cup, spoon or pencils and crayons. She drooled until the age of 2 years.
She was toilet trained at 2 1/2 years.
Kira has had 2-3 ear infections per year. She also gets frequent colds. She is on prophylactic antibiotics. She also has a history of eczema. There are no known allergies. She has had one episode of urinary tract infection.
Kira lives with her parents and younger brother Michael. Michael is 3 years old and developing well. He is reported to be shy. Mrs, Baker, age 33 is in good health. She has B.S. and M.S. degrees and is a medical copywriter in an advertising agency. Dr. Baker, age 52, is in good health. He is an M.D, , Ph.d and is the executive director of microbiology in a biotech company. There is no history of developmental problems on either side of the family.
Physical Examination: Kira was a pretty little girl. Her left eye was slightly smaller than the right, otherwise there were no dysmorphic features. Examination of the head and neck area was normal, including both ears. Dentition was normal. Auscultation of the heart and lungs were normal. The abdomen was soft, there was no hepatosplenomegaly. There was no scoliosis or midline defects. Genitalia were prepubertal female. There were no neurocutaneous lesions. Sidney crease was present on the right side. There was no major asymmetry of the extremities.
Neurological Examination: Kira was alert and active. As soon as the examiner entered the room she became suspicious and ran to her mother. She did not move away from her mother until she was ignored for a length of time and felt reassured. When she warmed up she became more sociable. She had a high activity level once she felt at ease. She made good eye contact but it was not sustained. For each task requested she would cooperate briefly, then become oppositional again. She was whiny and her first response to any task was “No, I don’t want to do it.” During this entire session she was not heard talking to herself but she did flap her hands for a few minutes while jumping in place. She also twirled her hair for a minute or so. She did not do any repetitive task such as turning the light off and on or turning the water off and on. She did not hum to herself. She did not laugh or cry inappropriately. Although her social interaction was not normal, she was not in a world of her own. She frequently asked her mother to read her a storybook and followed the story carefully, correcting her mother at intervals.
She did not initiate much speech except when asking her mother to read her a book but when she spoke she was fluent, appropriate and intelligible. Her sentences were 4-5 words long.
Muscle tone and strength were normal. Deep tendon reflexes were 2+ and symmetrical bilaterally. Plantar responses were flexor bilaterally. Her gait was normal. She walked on her heels and toes satisfactorily. She could not walk in tandem. She could not skip, hopping was limited. She stood on each foot for 2 seconds. She picked up a cheerio with a neat pincer grasp. No tremors were noted during fine motor tasks. She used her right hand predominantly , including writing, but used her left hand for building with blocks. She did not like to be touched, although she permitted the entire physical examination over a period of time.
Pupils were equal and reactive to light. Extraocular movements were full. Red reflexes were present bilaterally but discs were not visualized. There was no drooling. Other cranial nerve functions seemed normal.
On developmental assessment, delays were noted predominantly in the fine motor adaptive and personal/social areas. She built a tower of 8 cubes but could not imitate a bridge. She imitated vertical and horizontal lines and correctly picked the longer of two lines. She drew a person with three parts. She could not copy a circle or a cross. She recognized several colors. She comprehended prepositions and followed directions appropriately. She named opposites and defined words. She named the composition of a few items. She comprehended cold, tired and hungry. She used plurals and gave her first and last name. She jumped in place and did a broad jump satisfactorily. She threw a ball overhand and kicked a ball forward. She hopped on one foot for a few seconds. She could balance on one foot for only 2 seconds. By history she cannot dress herself completely and does not yet button her clothing. Kira correctly identified three letters of the alphabet.
Summary: Kira is a 4 1/2 year old girl with a history of poor social skills and mild developmental delays. She does not interact well with others, has a high activity level and is oppositional. Perinatal history is positive for premature labor at 28 weeks suppressed with medications, oligohydraminos, breech presentation and cesarean section delivery. Gestation was 37 1/2 weeks. Congenital torticollis was noted at birth and resolved with physical therapy. X-rays of the cervical spine done at the Children’s Hospital of Philadelphia were normal. Early motor milestones were slightly delayed, although she was walking without assistance by one year of age. Fine and gross motor coordination difficulties have been noted. Language milestones were achieved in the normal range, if not early. Family history is negative.
Growth parameters are in the normal range, including head circumference. Mild facial asymmetry is noted, the left eye being smaller than the right. General physical examination otherwise is normal. Neurological examination does not show any focal or lateralizing findings. Fine motor difficulties are noted. Behavioral observations include slow to warm up, lack of initiation of interaction, short attention span, easy distractibility, oppositional behavior and poor motivation to perform tasks. She makes good eye contact, though not sustained. There is no echolalia, no repetitive activities and no tuning out. She does show some self stimulatory behaviors in the form of jumping in place, flapping her arms and twirling her hair. Hand functions are purposeful. While she has impairment of social skills, they do not appear to be to a degree where a diagnosis of pervasive developmental disorder can be made at this time.
Developmental delays are noted in the fine motor adaptive areas but not in the language area.
1. Developmental delays in fine motor adaptive and personal/social areas.
2. Impairment of social skills.
3. Language skills tested are age appropriate.
4. Self stimulatory behaviors in the form of hand flapping and twirling of hair.
1. Since Kira is not able to function in a regular preschool setting, she should be evaluated for placement into a preschool handicapped program. In the interim she may benefit from group play therapy and/or social skills program.
2.No neuroinvestigative studies are indicated at this time.
3. Neurodevelopmental re-evaluation in 6 months.