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Question

Difficulty: HardNormal Growth and Development

A male child is evaluated by his pediatrician on his fourth birthday for a routine health maintenance visit. His parents state that he is an active and happy child but express significant anxiety regarding his development and school readiness. According to his mother, the patient is unable to draw a triangle, cannot skip across the room, and requires assistance to tie his shoelaces. The parents note he has an older cousin of the exact same age who can perform all these tasks. On examination, the child is cooperative and interactive. He is able to hop on one foot, catch a bounced ball, copy a cross, and draw a person with four distinct body parts. His speech is completely intelligible to the physician, and he tells a detailed story about a recent trip to the park. He easily engages in cooperative, turn-taking play with a toy set in the examination room. Which of the following is the most appropriate next step in the management of this patient?

  1. A
    Referral to a pediatric physical therapist
  2. B
    Administration of a standardized autism screening questionnaire
  3. Reassurance and routine follow-upAnswer
  4. D
    Referral for comprehensive psychoeducational testing
  5. E
    Referral to a pediatric occupational therapist

Answer

Reassurance and routine follow-up
The correct action is to provide reassurance and schedule routine follow-up because the patient is exhibiting perfectly normal, age-appropriate developmental milestones across all domains for a 4-year-old. At age 4, children are expected to copy a cross, draw a person with 2 to 4 body parts, hop on one foot, catch a bounced ball, speak with 100% intelligibility, tell stories, and engage in cooperative play. The parents' concerns center on tasks (drawing a triangle, skipping, and tying shoelaces) that are classically achieved at 5 years of age. Therefore, there is no clinical indication for intervention.

Step-by-Step Solution

1
Analyze the child's current demonstrated abilities.
The child hops on one foot, catches a bounced ball, copies a cross, draws a 4-part person, has 100% intelligible speech, and engages in cooperative play.
These abilities represent the expected gross motor, fine motor, language, and social milestones for a 4-year-old child.
2
Evaluate the parents' specific developmental concerns.
The parents are concerned because the child cannot draw a triangle, skip, or tie shoelaces.
It is necessary to determine the expected age of acquisition for these specific missing skills.
3
Compare the missing skills to standard milestone charts.
Drawing a triangle, skipping, and tying shoelaces are milestones normally achieved at 5 years of age (60 months).
Because the child is exactly 4 years old, the absence of 5-year milestones is completely normal and does not constitute a developmental delay.
4
Determine the most appropriate management step based on the findings.
Since the child is developing normally for his age, no specialized referrals or testing are needed.
Reassurance and routine follow-up is the correct standard of care for a child exhibiting normal growth and development.

Key Concept

Normal developmental milestones at 4 versus 5 years of age
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Topics

Normal Growth and Development

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