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Difficulty: MediumNormal Growth and Development

A 36-month-old girl is evaluated during a routine pediatric visit. Her father shares concerns raised by her new daycare provider regarding the child's developmental progress. According to the provider, the child is 'falling behind' because she cannot draw a square during arts and crafts and places both feet on each step when walking down the playground stairs. The father also notes that while he easily understands his daughter, extended family members occasionally ask her to repeat herself. The child currently speaks in three-word sentences, easily pedals a tricycle, and engages in imaginative play with her toys. She accurately states her age and gender when asked. Vital signs are normal, and physical examination shows no abnormalities. Based on her current developmental status, which of the following is the most appropriate next step in management?

  1. Routine preventive care and anticipatory guidanceAnswer
  2. B
    Comprehensive audiological evaluation
  3. C
    Referral for pediatric physical therapy
  4. D
    Referral for speech-language pathology assessment
  5. E
    Administration of a targeted autism spectrum screening tool

Answer

Routine preventive care and anticipatory guidance
The correct answer is routine preventive care and anticipatory guidance because this child is meeting all age-appropriate developmental milestones for a 36-month-old (3-year-old). At 3 years of age, normal gross motor skills include riding a tricycle and alternating feet when walking up stairs; alternating feet when walking down stairs is not typically achieved until age 4. Fine motor skills at 3 years include copying a circle and using utensils, whereas copying a cross (age 4) and a square (age 4.5-5) occur later. Normal language development at age 3 is characterized by 3-word sentences and speech that is approximately 75% intelligible to strangers. Finally, knowing one's age and gender and engaging in imaginative play are normal 3-year social milestones. Because she exhibits normal development, no further diagnostic evaluation is required.

Step-by-Step Solution

1
Evaluate the child's gross and fine motor milestones.
Pedaling a tricycle is a normal 3-year gross motor milestone. Inability to alternate feet going down stairs and inability to draw a square are normal, as these are 4-year and 4.5-year milestones, respectively.
To determine if the daycare provider's motor concerns represent a true developmental delay.
2
Assess the child's language and social milestones.
Speaking in 3-word sentences, being 75% intelligible (occasional difficulty by strangers), imaginative play, and knowing age/gender all perfectly align with 3-year-old milestones.
To determine if the father's speech concerns or any social deficits warrant intervention.
3
Determine the appropriate clinical intervention.
Since all milestones are appropriate for a 36-month-old, the presentation represents normal development.
Normal development requires reassurance and routine anticipatory guidance, avoiding unnecessary testing.

Key Concept

Normal pediatric milestones at 3 years of age include riding a tricycle, speaking in 3-word sentences, 75% speech intelligibility to strangers, and imaginative play.
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Topics

Normal Growth and Development

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