Pediatric Developmental Assessment

Voiceover: Welcome to NP Certification Q&A, presented by Fitzgerald Health Education Associates. This podcast is for NP students studying to pass their NP certification exam. Getting to the correct test answers means breaking down the exam questions themselves. Expert Fitzgerald faculty clinicians share their knowledge and experience to help you dissect the anatomy of a test question so you can better understand how to arrive at the correct test answer. So, if you're ready, let's jump right in.

Sally Miller: A 5-year-old child presents for evaluation with her mother. The mother is concerned that the child might have autism spectrum disorder and asks for a comprehensive evaluation. As part of a developmentally appropriate assessment, the NP recognizes that which of the following is the appropriate approach to assessing the child's affect, coordination and motor skills, speech, attention span, capacity for complex thinking and interaction.

Hm, would it be playing with the child on the floor, administering the Sally-Anne test, a complete neuropsychiatric assessment, or evaluating responses to a CRAFFT questionnaire?

What is the question for you? Remember, is you recognize that which of the following is the appropriate approach to assessing affect, coordination, motor skill, speech, attention span, and capacity for complex thinking and interaction. Of those four answer choices, A is the correct answer.

Playing with the child is an excellent interview technique with young children. An appropriately structured play session can allow the examiner to assess everything we just said and more: motor skills, problem solving, attention span, frustration threshold and response to frustration, verbal and non-verbal interaction. I mean, obviously it depends on the child's age, what kind of games you play or things that you do, but it is important to evaluate how the child, very young children, what are their motor skills, can they pick up, can they move, can they carry, um, what's their threshold for frustration. I mean, there are tasks that at certain ages, you know, they cannot be expected to complete, and you want to see how long they try, what they do when they realize they can't do it, um, what's, are they engaging in appropriate verbal interaction? Can they structure sentences to the extent that you think is appropriate at that age?

I mean, of course, you have to know the age of the child and you have to know what you're expecting. But, and this isn't something that a lot of psych do unless you really specialize in pediatrics, most of you really won't think much about this after you take your boards and go out and get a job and go to work. But because your boards exam is through the lifespan, uh, pediatrics is represented there. That's an absolute certainty. And I can tell you from experience that the majority of pediatric questions really are about development, about how to bond with a child patient, how to connect, what assessment techniques are different than, say, from an adolescent or adult. So these are some things that you want to be familiar with.

And you know, the simplest answer is often the best one: playing with the child on the floor. It can allow you to make all sorts of observations, like I said, about their motor skills, about their interpersonal relationships, their verbal ability, um, paying attention to things, how they respond when they can't do something, and all kinds of stuff in between. So that's the place to start. That's the best answer to the question.

You know, depending on what information you gather from that initial interview that you have with the patient, you might have to refer them on for a complete neuropsychiatric assessment. Um, or maybe not, maybe everything will look developmentally very appropriate and you don't see any flags for autism spectrum disorder. But we have to start with our own interview. Not every patient that comes through the door gets referred for neuropsychological testing because the parent asks for it. We're expected to be able to evaluate those patients and then determine if a referral is necessary or not. So A is the best answer.

B is not correct. Now, the Sally-Anne test, um, I don't even know if you know what it is. It's a classic psychological test that has been used historically as a screening tool to assess for autism, to assess what's referred to as theory of mind, or the child's ability to attribute different mental states to others than their own. I mean, remember, young children are characterized by being egocentric. They typically can't see the world outside of themselves, everything as it pertains to them. So the Sally-Anne test is a very, very simple, like I said, it's a classic. It's one of those things that's usually still taught in some context and then maybe not very often done anymore. At one time it was considered a very useful tool for screening for autism spectrum disorder. Um, in recent years it's come under a little bit of scrutiny, but I'll tell you what, I mean, I don't see a lot of children, but I do see some, and probably half the kids I see, one of the first things out of the parents' mouths is, "Do you think that, you know, she might have autism, or do you think she might be on the spectrum?" And, you know, the Sally-Anne test, it certainly isn't a hard and fast rule, but it absolutely is a really interesting place to start. Um, a normal response doesn't necessarily rule it out, but an abnormal response should definitely get your attention.

I mean, it's very simple and done right there in the office. It's, if you don't know what it is, Sally-Anne is where a child watches a scenario where there are two dolls, you know, and you can set this up right in front of them if you see children and have the resources in your office. You have two dolls, Sally and Anne. Sally has a basket and Anne has a box. And so what the child sees, what your setup is, is that Sally places her marble in her basket and then Sally leaves the room. While Sally's out of the room, Anne, the other doll, takes the marble out of Sally's basket and Anne puts it in her own box. When Sally comes back and she wants to play with her marble, the child is asked, "Where do you think Sally will look for her marble? Where do you think she's going to look for it?"

And the correct answer is that the child expects that Sally will look in her own basket, where she put it before she left, because the child should understand that Sally doesn't know the marble was moved. Remember, she was out of the room. Sally doesn't know that Anne took the marble and put it in her box. All Sally knows is she had a basket, she had a marble, she put the marble in the basket and left. When she comes back, if she wants her marble, the first place she's going to look is in her own basket where she put it.

So when the child says, "Oh, Sally will look in the basket," that tells us that the child recognizes that Sally is looking at this from her perspective. All she knows is that she put the marble in the basket. Now, if the child says, when Sally comes back, she will look in Anne's box, that demonstrates that the child can't separate his or her own knowledge from the perspective of Sally the doll. Remember, while the patient knows that the marble has been moved, Sally the doll doesn't. So, if the patient says, "Oh, when she comes back, she'll look inside of Anne's box," that tells you that the child can't separate the two thought processes. She can't recognize that Sally has a different perspective.

So, I know I'm probably making it sound more complicated than it is, but you get the idea. If nothing else, you know, you just might remember, just put a little highlight on the Sally-Anne test, which is a very easy office-based screening that you can do when you are initially evaluating for autism spectrum disorder.

Um, C is not the correct answer. That might be indicated if the NP believes that referral is necessary after doing your own examination. Remember, first you're going to get on the floor and play with the patient, you will make your assessment, and then you might decide that the patient does need to be referred on, but that's after you do your assessment.

And D is incorrect. You know, the CRAFFT questionnaire is a screening tool for substance use disorder in adolescents. So that's not going to give you any info about autism spectrum disorder.

And again, if you look at some of these answer choices and go, "Wait, what's that? I don't know, oh no, I'm overwhelmed," just back up. I mean, very often the simplest, or most, you know, most straightforward, simplest, least invasive answer is going to be the best one. And the first thing you do with any patient of any age is to examine them yourself. And with children, you know, that play, appropriately structured play, can tell you an awful lot.

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