By Karen J. Marcdante, MD Robert M. Kliegman, MD
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Certain general medical problems are found more frequently in delayed and developmentally disabled people (Table 10-5), especially if the delay is part of a known syndrome. Some children may have a limited life expectancy. Supporting the family through palliative care, hospice, and bereavement is another important role of the primary care pediatrician. Chapter 10 u Evaluation of the Child with Special Needs 31 Table 10-5 Recurring Medical Issues in Children with Developmental Disabilities PROBLEM Motor Diet ASK ABOUT OR CHECK Range of motion examination; scoliosis check; assessment of mobility; interaction with orthopedist, physical medicine and rehabilitation (PM&R), and physical therapist/ occupational therapist as needed Dietary history, feeding observation, growth parameter measurement and charting, supplementation as indicated by observations, oro-motor therapist as needed Sensory impairments Functional vision and hearing screening; interaction as needed with ophthalmologist, audiologist Dermatologic Examination of all skin areas for decubitus ulcers or infection Dentistry Examination of teeth and gums; confirmation of access to dental care (preferably with ability to use sedation) Behavioral problems Aggression, self-injury, pica; sleep problems; psychotropic drug levels and side effects Seizures Major motor, absence, other suspicious symptoms; monitoring of anticonvulsant levels and side effects Infectious diseases Ear infections, diarrhea, respiratory symptoms, aspiration pneumonia, immunizations (especially hepatitis B and influenza) Gastrointestinal problems Constipation, gastroesophageal reflux, gastrointestinal bleeding (stool for occult blood) Sexuality Sexuality education, preventing abuse, hygiene, contraception, menstrual suppression, genetic counseling Other syndromespecific problems Ongoing evaluation of other “physical” problems as indicated by known mental retardation/developmental disability etiology Advocacy for services and enhancing access to care Educational program, family supports, financial supports, legislative advocacy to support programs SELECTED CLINICAL PROBLEMS: THE SPECIAL NEEDS CHILD Mental Retardation MR is defined as significantly subnormal intellectual functioning for a child’s developmental stage, existing concurrently with deficits in adaptive behaviors (self-care, home living, communication, and social interactions).
Providing confidentiality is crucial, allowing for optimal care (especially for obtaining a history of risk behaviors). When assessing development and behavior, confidentiality can be achieved by meeting with the adolescent alone for at least part of each visit. However parents must be informed when the clinician has significant and immediate concerns about the health and safety of the child. Often the clinician can convince the adolescent to inform the parents directly about a problem or can reach an agreement with the adolescent about how the parents will be informed by the physician (see Chapter 67).
Motor Assessment The comprehensive neurologic examination is an excellent basis for evaluating motor function, but it should be supplemented by an adaptive functional evaluation (see Chapter 179). Observing the child at play aids assessment of function. Specialists in early childhood development and therapists (especially occupational and physical therapists who have experience with children) can provide excellent input into the evaluation of age-appropriate adaptive function. Chapter 10 u Evaluation of the Child with Special Needs 27 Table 10-1 Information to Be Sought during the History Taking of a Child with Suspected Developmental Disabilities ITEM POSSIBLE SIGNIFICANCE ITEM POSSIBLE SIGNIFICANCE Parental concerns Parents are quite accurate in identifying development problems in their children.
Nelson Essentials of Pediatrics , Seventh Edition by Karen J. Marcdante, MD Robert M. Kliegman, MD