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Difficulty: EasyNormal Growth and Development

A 3-year-old boy is brought to the clinic by his parents for a routine well-child visit. The parents express concern about his development, noting that he is unable to draw a cross or a square. They mention that their older daughter was able to draw these shapes at his age. They report that the patient is otherwise active and playful. He can pedal a tricycle and alternate his feet when walking up the stairs. He feeds himself with a spoon and can build a tower of 9 blocks. He speaks in 3-word sentences and strangers can understand approximately 75% of what he says. His physical examination is unremarkable. Which of the following is the most appropriate next step in management?

  1. Reassurance that his development is age-appropriateAnswer
  2. B
    Referral for pediatric occupational therapy
  3. C
    Referral for comprehensive developmental evaluation
  4. D
    Audiology evaluation and speech therapy referral
  5. E
    Genetic testing with a chromosomal microarray

Answer

The most appropriate next step is reassurance that the child's development is age-appropriate.
The correct action is reassurance because this 3-year-old boy exhibits completely normal development. A 3-year-old child is expected to ride a tricycle, alternate feet going up stairs, build a tower of 9 blocks, and speak in 3-word sentences that are 75% intelligible to strangers. In terms of drawing and fine motor skills, a 3-year-old is expected to copy a circle. The ability to copy a cross and a square typically emerges at age 4, while a triangle is copied at age 5. Therefore, the parents' concern about his inability to draw a cross or square is unfounded, and the appropriate management is to reassure them that his development is on track.

Step-by-Step Solution

1
Identify the patient's chronological age and the parents' primary concern.
The patient is a 3-year-old boy whose parents are concerned that he cannot draw a cross or a square.
Establishing the patient's age and the specific concern is required to compare against expected developmental milestones.
2
Evaluate the patient's current motor, language, and social skills against expected milestones for his age.
Pedaling a tricycle, alternating feet on stairs, building a 9-block tower, and speaking in 3-word sentences with 75% intelligibility are all normal, reassuring 3-year-old milestones.
A comprehensive milestone inventory determines if there is any true delay across different developmental domains.
3
Determine the age at which a child is expected to copy a cross and a square.
A typically developing child is expected to copy a circle at age 3, a cross at age 4, and a square at age 4.
This determines whether the parents' specific concern represents a true delay or a misinterpretation of normal development.
4
Select the appropriate clinical management based on the developmental assessment.
Because the child is developing normally for a 3-year-old, no further testing or referral is needed; the physician should provide reassurance.
Avoiding unnecessary medical interventions is a key principle when development is normal.

Key Concept

Normal Growth and Development
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Topics

Normal Growth and Development

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