Behavior/Mental Status - Establishing Relationship

This 2.5 year old is apprehensive about being examined and isn't quite sure she wants to be there. The finger puppets are used in attempt to establish rapport and involve the child in play. The child's social interactions and motor skills are observed during this time. The child is also examined on the mother's lap.

Behavior/Mental Status - Follows Commands

At this age verbal instructions without demonstration are understood. The child can follow two-step commands.

Behavior/Mental Status - Points to Pictures

The girl is first asked to name the pictures but doesn’t cooperate enough to determine if she knows their names. So the examiner switches strategy and asks her to point to the picture he names. She is able to do this for all five pictures. She asserts her autonomy by using her foot instead of her finger. These pictures are from the Denver II.

Behavior/Mental Status - Names Pictures

Later on in the exam she cooperates enough to demonstrate that she is able to name all five pictures that are shown to her, which is the next developmental level above pointing to them. The next level after naming would be identification by the action of the picture, such as asking which one flies. Pointing to 4 pictures should be accomplished by 2.5 years, naming by 3 years and identification by action by 4 years.

Behavior/Mental Status - Response to Questions

The girl is shown a picture in an attempt to get her to talk. She is shy and doesn’t talk much but responds to questions with yes and no. She is putting two words together in a simple sentence. A child’s earliest sentences usually contain important content words and lack grammatical words. A 3 year old forms a 3 to 4 word sentence and uses pronouns and plurals.

Behavior/Mental Status - Pointing to and Naming Body Parts

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Fine Motor/Coordination - Using Puppets

Using finger puppets facilitates coordination testing. First the girl is asked to place the puppets on her finger, which shows that she accurately reaches a target without ataxia. The girl is then taught how to do finger to nose by having her touch the puppet’s nose then her nose.

Fine Motor/Coordination - Using Measuring Tape

A measuring tape can also be used to test coordination. As the girl reaches for the tip of the tape to pull it out and has to extend the arm to reach the target, she is being tested for dysmetria. Having her manipulate the tape measure and work the control button is testing hand coordination. The examiner tries to get her to click the button but she doesn’t do it. This was an attempt to test repetitive movements.

Fine Motor/Coordination - Block Tower

The girl is able to build a 5 block tower and almost gets to 6 blocks. She’s not sitting in the best position nor does she have the most stable platform to build a tower. A 2.5 year old should be able to build a 6-8 block high tower. At 3 years, the child is able to build a 3-block bridge. Assessing if a child is developmentally age appropriate is not based on one particular test but rather how they do on several different tests as well as their overall performance.

Fine Motor/Coordination - Drawing

The girl imitates drawing a horizontal line as well as making circular shapes. At 3 years of age a child should be able to draw a circle and at 4 years old can copy a cross.

Motor - Tone

Upper and lower extremity tone is tested using passive range of motion. The girl is apprehensive about this but using the finger puppet as part of the exam helps.

Motor/Reflexes - Deep Tendon Reflexes

This segment of the exam illustrates the problems associated with obtaining deep tendon reflexes. The reflex hammer is turned into a horse and initially she allows the examiner to test the right upper extremity. Notice that after testing for the brachioradialis reflex she becomes uncooperative. One of the ways to reduce apprehension in the child is to place your thumb or index finger over the tendon to be examined and tap on it rather than directly tapping on the child’s tendon. It's less threatening.

Motor - Kicking and Throwing a Ball

At this age, the child is able to kick the ball and throws the ball overhand to the examiner. A ball is a good tool to use during the neurological examination because the child enjoys playing with it and it allows the examiner to see both fine and gross motor skills that the child has developed.

Motor/ Gait - Walking, Running

At this age, the gait is steady, well coordinated and no longer wide-based. The arms are down to the side and there are normal associated movements. The hands are no longer used when getting up off the floor or sitting down on the floor. The child is able to run.


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