59:E- request a psychoeducational evaluation
The child described in the vignette has symptoms that are concerning for a reading learning disability. The most
helpful intervention is further evaluation of his academic difficulty by requesting a psychoeducational evaluation.
Reading is a complicated endeavor that involves the integration of multiple neurologic pathways. Although vision
is necessary for reading, complex visual processing facilitates reading and comprehension of written language.
Children who have common ophthalmologic disorders may have academic difficulty only when there is an inability
to see adequately what is written on the page. Mild or correctable vision deficits rarely cause reading or academic
problems. Of note, there is no evidence to support the value of eye exercises or the use of special tinted lenses
as therapy for reading difficulties.
Brain magnetic resonance imaging and electroencephalography are unlikely to provide useful information in a
child who has normal findings on physical examination and a single febrile seizure. He should receive routine eye
evaluations, but given the near-normal vision documented on your office screening, he is unlikely to have a vision
disorder that is causing his reading difficulty. For children who have vision loss, a functional vision assessment,
which evaluates how the child uses vision to perform routine tasks, can be useful.
107: D- specific learning disability
Learning disabilities are characterized by an unexpected difficulty in one academic area in children who otherwise
have the intelligence, motivation, and educational opportunity to learn. The child described in the vignette has
normal cognition, with a full scale intelligence quotient of 105 and a normal math performance, but subnormal
reading performance on achievement testing, a pattern that is concerning for a specific learning disability. For the
boy in the vignette, the disability appears to be in reading.
Children who have learning disabilities may appear inattentive in academic situations in which they do not
understand the material, and attention-deficit/hyperactivity disorder (ADHD) may be comorbid with learning
disability. However, ADHD is unlikely to be the primary diagnosis for the boy in the vignette. Children who have
mental retardation have intelligence quotients of less than 70 plus associated limitations in adaptive functioning.
Testing conditions for the boy in the vignette are unlikely to have been poor, given his performance on cognitive
testing and the math portion of the achievement testing. Only severe vision impairment would affect the ability to
read and would have been obvious through history or physical examination.
123: A- delayed sleep onset
Most children who receive medication for treatment of attention-deficit/hyperactivity disorder (ADHD) are
prescribed stimulant medications, such as methylphenidate or dextroamphetamine. Stimulants generally are
considered safe, with generally mild and short-lived adverse effects. The most common adverse effects are
decreased appetite, irritability, and delayed sleep onset. Approximately 15% to 30% of children experience motor
tics, most of which are transient and do not represent an absolute contraindication to continuing with the
medication. Although stimulants do not cause Tourette syndrome, they may unmask the tic symptoms.
The safety profile of stimulants is being reviewed, and in February 2006, the United States Food and Drug
Administration placed a black box warning for cardiovascular risk, including sudden death and stroke, especially
in children who have underlying heart disease.
Other medications for ADHD include atomoxetine and tricyclic antidepressants. Atomoxetine is a norepinephrine
reuptake inhibitor that had a similar adverse effect profile to stimulants in clinical trials, but has been associated
with nausea, hepatic injury, and risk of suicidal ideation. Tricyclic antidepressants typically cause sedation and
related anticholinergic adverse effects such as dry mouth and constipation.
If the child in the vignette experiences delayed sleep onset, the condition can be managed by changing the
timing of the medication dose or decreasing an afternoon dose. Depression and hallucinations are rare adverse
effects of stimulant medication. Tics are less common than changes in sleep onset. A child who receives stimulant
medication for treatment of ADHD is more likely to have weight loss or lack of weight gain related to decreased
appetite than weight gain.
139: B- dosing outside school hours allows parents to monitor medication effect
Children who have attention-deficit/hyperactivity disorder (ADHD) commonly have difficulty attending to and
completing tasks both at home and school. Families may resist giving medication outside of school hours because
they assume that the same degree of attention needed in a school setting is not necessary in the child's other
settings. However, best results from stimulant medication therapy have been noted when children receive
medication in all of their typical settings. Additionally, parents will be more aware of medication adverse effects
and adequacy of dosing if they observe the child when he or she is taking the medication.
An after-school dose of medication may be necessary for the child to perform successfully in after-school and
home activities if the medication effects have worn off at the end of the school day. There is no need to change
the type or the dosing of medication used during weekends and holidays. Continuous dosing throughout the year
does not make a child more tolerant to stimulant medications, and drug holidays are not necessary.
155: E- the parents should be trained in behavior modification techniques
Behavior modification is a general category of therapy that refers to principles and techniques based on learning
theory and used to change behavior. Behavioral techniques are used to either strengthen or maintain desired
behaviors or to decrease or eliminate undesired behaviors. For example, parental praise or token economies are
examples of techniques used to reinforce behavior, and time-out is a technique used to decrease or eliminate a
The child described in the vignette has oppositional behavior that may respond to behavioral management. He is
doing well in school and, therefore, probably does not need cognitive testing. Individual counseling may be used
as an adjunct, but he is more likely to respond to consistent behavior management. Behavioral approaches
should be tried before using medication to control behavior. The behavioral plan should be instituted both at
home and in school, with communication between teacher and parents to maintain consistency.
171: D- the number of floors in the school
The time of diagnosis and medical, social, and educational transitions are common stress points for parents in the
life of their child who has a developmental disability. The need for increasing medical equipment and assistance,
such as braces, a wheelchair, or a gastrostomy tube, may cause significant stress. Similarly, entering
kindergarten, middle school, junior high school, and high school each present challenges. A child likely needs re-
evaluation of school services provided at those times and may require significant testing or accommodations for
differing physical facilities.
For the ambulatory boy in the vignette, the most likely difficulty he will encounter is numerous stairs in a
multilevel school that may be tiring for him to climb and descend. He is healthy and is unlikely to have problems
with sleep apnea or need pulmonary function tests until his disease has progressed further. Likewise, at his
present level of function, he does not need a wheelchair or communication device. However, most children who
have Duchenne muscular dystrophy need educational support for related learning disabilities that may manifest
43: D- refer him for mental health evaluation
The boy described in the vignette has behavioral manifestations of depression. It is not unusual for youth to have
occasional feelings of sadness, but it is important to consider if the child is truly depressed and if there is
impairment of daily functioning. The Diagnostic and Statistical Manual of Mental Disorders edition IV criteria for
major depressive disorder (MDD) are depressed or irritable mood, decreased interest, or decreased pleasure that
lasts for at least 2 weeks accompanied by changes in both cognitive and physical functioning. Dysthymic disorder
is a less severe type of depression that involves chronic symptoms that last for at least 1 year. Approximately 2%
of school-age children and 4% to 6% of adolescents have MDD at some period. Prior to puberty, there is equal
prevalence in boys and girls. After puberty, there is a 2:1 ratio of girls to boys for major depressive disorder after
The following two questions are recommended for MDD screening by the United States Preventive Services Task
Force: "Over the past 2 weeks have you ever felt down, depressed, or hopeless? " "Have you felt little interest or
pleasure in doing things?" Depending on the answer to these questions, additional screening or diagnostic tools
or referral to a mental health specialist may be necessary. Based on the history of changes in affect of the boy
described in the vignette, referral for mental health evaluation is appropriate. It is important to note that suicide
is the third leading cause of death among children and adolescents and that depression is an important risk factor
for suicide. The goals of treatment for MDD are to ensure the child's safety and establish good communication
between the child and his or her parents.
The overt sadness exhibited by the boy in the vignette is not characteristic of attention-deficit/hyperactivity
disorder. Having him rejoin the basketball team without addressing his mood would not treat the underlying
problem. Although his grades have declined recently, this is not unusual in MDD, and other findings on the
history are not supportive of a learning disability that requires educational evaluation. Having the boy return for
follow-up in 1 month without any appropriate treatment places him at possible emotional risk.
59: B- recommend extracurricular activities for the girl
The term "learning disabilities" refers to a heterogeneous group of disorders manifested by significant difficulties
in the acquisition and use of listening, speaking, reading, writing, reasoning, or mathematical abilities. Such
disorders are intrinsic to the individual and presumed to be due to central nervous system dysfunction. Most
definitions of learning disability include a discrepancy between ability as measured on an intelligence test and
actual achievement in academic skills. The prevalence is estimated to be 3% to 5% in the school-age population.
A vital aspect of the appropriate management of learning disabilities is maintenance of the child's self-esteem,
which is affected adversely by repeated failure. Therefore, it is important to work closely with parents so they
understand that the failure is not the child's fault or purposeful.
Because the child described in the vignette displays feelings of poor self-worth, it is important for her to engage
in activities that give her a sense of accomplishment, such as extracurricular activities. Having her sister help her
with her homework may increase sibling rivalry. Although additional educational testing may provide further
information about the child's learning needs, it does not address her parents' concerns regarding the girl's
insecurity and poor self-esteem. There is no indication in the vignette that the child is having problems paying
attention or that her educational needs are not being met. Therefore an evaluation for attention-
deficit/hyperactivity disorder or hiring an educational advocate are not indicated.
75: B- explain to the parents that they must consider the benefits, risks, and evidence regarding
efficacy for each treatment
Complementary and alternative medicine (CAM) is used frequently among children who have chronic illness or
disability such as mental retardation or autism. Many parents become frustrated with biomedical therapies due to
uncertainty of a cure and lack of an active role in the care plan. They also may be attracted to an approach that
they perceive to be more "natural. "
A number of CAM therapies have been advocated for children with developmental disabilities, including those who
have autism, but to date no results from controlled trials support their efficacy. For example, there is no scientific
evidence that vision therapy (eye exercise) or "patterning" (series of exercises promoted to enhance
development) is effective in remediating pediatric developmental and neurologic conditions. Sensory integration
therapy also lacks evidence-based research, although parents may report benefit for a child who has a high
degree of sensory defensiveness. Other CAM therapies with no proven efficacy such as the use of hyperbaric
oxygen or chelation may involve potential risks to the child as well.
The pediatrician is in a unique situation to help families evaluate CAM therapies and provide guidance regarding
their benefits, risks, and evidence of efficacy. In particular, families should be informed about placebo effects and
the need for controlled studies, as well as potential adverse effects. Discussion of CAM should not be referred to
the child's special education teacher. Dismissal of CAM therapies as generally ineffective may be interpreted as a
lack of sensitivity to the family's perspective. Referring the family to a counselor may help them discuss
frustrations but would not address their question regarding the use of alternative therapies. Although the child
has both mental retardation and autism, the clinician should be sensitive to the family's desire to have the child
meet her cognitive potential.
11: B- begin walking between 18 and 22 months
Legal blindness is defined as central visual acuity with corrective lenses of 20/200 or less in the strongest eye or
a limited visual field that extends to an angle of 20 degrees. Congenital blindness occurs in 30 per 100,000
births. More than 50% of children who have visual impairment also have developmental disabilities, such as
cognitive-adaptive disability, seizures, hearing impairments, and learning disorders. In many of these cases, the
disabilities result from central nervous system pathology. Postnatal blindness, which accounts for approximately
8% to 11% of all childhood blindness, can be caused by infections, trauma, or tumors. Retinoblastoma is the
most common primary malignant intraocular tumor of childhood. The initial finding in most cases is a white
pupillary reflex (leukokoria) (Item C11). Advanced tumors may be treated with enucleation.
Children who have congenital or acquired (eg, due to retinoblastoma) blindness without associated neurologic
abnormalities should not be at increased risk for motor or cognitive impairment. They are not at increased risk
for language-based learning disabilities or autism spectrum disorders. However, children who have significant
visual impairment may begin to walk at an older age (18 to 22 months) than sighted children due to different
exposure to motor exploration. They typically develop language skills at the same time (12 months) as sighted
children. Children who have visual impairments should be provided with much physical contact that includes
hugging and comforting. They should be encouraged to partake in self-help skills and exploration of their
27: A- reassure the mother that letter reversal can be normal through 7 years of age
Letter reversal in writing can be normal in children through 7 years of age. Dyslexia, a word recognition defect, is
a specific learning disability that is neurobiologically based. It is characterized by problems with the ability to
recognize words accurately and poor spelling and decoding skills. Its prevalence is as high as 17.4% of the
school-age population. Affected children have problems attaching the correct labels or names to letters and
words. They may call a "b" a "d" or read "saw" as "was." Because the problem is linguistic, not visual, affected
children do not have problems copying letters.
Backward writing and letter reversal occur commonly in early development for all children whether or not they
have learning disabilities. All children should receive routine vision screening, but a visual acuity problem would
not be the cause of the letter reversal for the boy described in the vignette. There is no scientific evidence that
vision therapy (eye exercise) is effective in the remediation of language-based learning disorders. Because letter
reversal still can be considered in the normal range of development at 6 years of age, psychoeducational
evaluation, neurologic evaluation, and occupational therapy are not indicated for this child.
139: B- explain that therapy at this age is parent-based training to promote appropriate development
in the home setting
Federal legislation for the provision of services to infants, toddlers, and preschool children who have disabilities
has evolved since 1986. From its inception as part of PL99-457 (the Education of the Handicapped Amendments)
through the most recent changes defined in PL 105-17 (Individuals with Disabilities Education Act, Part C),
legislative efforts uphold the rights of students and parents to the key components of a free and appropriate
public education. Federal regulations define early intervention services as services that "are designed to meet the
developmental needs of each child eligible under this part and the needs of the family related to enhancing the
The child described in the vignette will benefit from early intervention therapy, the goal of which is to enhance
the development of infants and toddlers who have disabilities and minimize their potential for developmental
delays. The services are designed to meet the needs of the child and family and promote the child's development
in natural environments. Therapy at this stage may be selected by the parents, and parent-based training in the
home is most appropriate for this child. Because language delays have been identified for this boy, his parents
should be encouraged to initiate services without delay. His speech probably will improve more slowly without
therapy, but it will not regress without therapy.
Participation in the Part C early intervention system for infants and toddlers is voluntary for the family; they have
the right to accept or decline specific early intervention services. Thus, declining such services does not constitute
Early intervention services were established to allow children who have developmental problems to reach their
potential. Research studies have identified specific times in which a child's brain is especially efficient at learning
specific information. Coordinated, community-based multidisciplinary programs for early intervention represent
effective public policy because they not only help to improve some children's cognitive outcome, but they also aid
in family functioning.
155: C- resource services for language arts and reading
The Individuals with Disabilities Education Act (IDEA) of 1990 (PL 101-476) defines the guidelines for education
of children in the United States who have specific learning disabilities. According to the "least restrictive clause"
in IDEA, children who have learning disorders should be integrated into the mainstream classroom as much as
The child described in the vignette is having learning issues in the area of reading and writing. The most
appropriate setting for him is in the mainstream class for all of his subjects except language arts and reading. For
these skills, he should receive extra educational support. Typically, this is accomplished by having the student go
to a specialized classroom (resource room) staffed by a special education teacher.
Preferential seating close to the teacher in a regular classroom will not address his areas of academic weakness.
Although he may benefit from additional tutoring and summer school, these strategies could be offered in
addition to resource services. Children who have more significant learning issues (eg, autism spectrum disorder,
cognitive impairment) may require a self-contained classroom that provides more individualized and intensive
43: E- social studies
A student who has a slow reading rate, reduced reading comprehension, and impaired short-term memory, such
as the girl described in the vignette, will encounter problems in "content" classes, which include subjects such as
science, history, and social studies. When children read texts in these subjects, they need to read factual
information and use the material in the text to obtain knowledge about the subject. This requires comprehension
of the text, which involves identifying and understanding the words.
To determine the meaning of a word, a reader first must decode and identify the word on the page. A slow reader
takes much longer to complete assignments and test questions. Further, individuals who have weakness in
understanding and remembering the text will have much more difficulty with homework assignments and on
examinations. The girl in the vignette will not have the same difficulty with art, music, creative writing, or
mathematics because these subjects do not demand the same emphasis on reading a text and recalling facts.
91: C- rubella virus
Congenital infections may lead to developmental sequelae in infancy and childhood, including visual impairment,
hearing loss, and intellectual disabilities (Item C91A). The infant described in the vignette has clinical findings
most consistent with congenital rubella syndrome (CRS). These findings include intrauterine growth restriction
(IUGR), absent red reflexes (due to cataracts), and bluish papules (Item C91B). Other clinical findings associated
with CRS include nerve deafness, microphthalmia, cardiac defects, meningoencephalitis, hepatomegaly, and
Maternal cytomegalovirus (CMV) infection is common, but 90% of infants who have CMV infection are
asymptomatic at birth. Maternal symptoms include a flulike illness that may involve fever, but a rash is not seen,
as reported by the mother in the vignette. Among the clinical findings of congenital CMV infection are
hepatomegaly, splenomegaly, jaundice, petechiae, chorioretinitis, IUGR, purpura, and microcephaly. CMV
infection is the leading nongenetic reason for sensorineural hearing loss and the most common congenital
infection to cause intellectual disability.
Congenital varicella infection may result in zigzag scarring of the skin, limb deformities, or cataracts.
Occasionally, severely affected infants may have central nervous system involvement with necrotizing cerebral
lesions or microcephaly.
Congenital toxoplasmosis presents with IUGR, anemia, jaundice, hepatosplenomegaly, intracranial calcifications,
hydrocephalus, microcephaly, and chorioretinitis, but not skin lesions.
A newborn infected perinatally with human immunodeficiency virus exhibits no symptoms or signs. Later, the
infant may develop subtle clinical findings, such as lymphadenopathy and hepatosplenomegaly, or nonspecific
symptoms, such as failure to thrive, chronic or recurrent diarrhea, interstitial pneumonia, or oral thrush. Central
nervous system involvement is variable, ranging from mild learning disabilities to severe mental retardation.