school readiness 08.20.2012
TRANSCRIPT
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School ReadinessMichelle Vo, M.D. PGY-5
Triple Board Morning Report
August 20, 2012
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One day in continuity clinic
J.J. is a 5 year old male who comes in with his mother and
father at the end of July for a well-child visit. He just turned five
this month. His mom wants to know if he should start
kindergarten this year as they originally planned, or if theyshould delay kindergarten entry so he will have a year to
become more mature.
J.J.s dad wants to know if they should delay kindergarten so that
J.J. can have an advantage when playing sports when he is
older.
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I have excellent timing.Salt Lake Tribune, August 19, 2012 (hot off the press!)
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Back to your office. You learn
moreJ.J. currently attends half-day preschool 3 days a week.
He was last seen in the clinic 2 years ago, when you noted that
he is a very active child who was fairly slow to warm up.
Mom says, He likes to have things a certain way. He needs
routines. She is worried that J.J. wont keep his shoes on at
school because he needs to have the seam in his socks exactly
right. He will also go to private school for kindergarten and
shes worried he may refuse to wear the uniform because hedoesnt like buttons.
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Now you are interested. So you ask
about:Separations: J.J.s mom was the one who had a hard time
separating from J.J. when he started preschool a year ago. She
cried. He was reportedly fine.
Mood: Most of the time hes really a happy kid
Sleep: J.J. has an elaborate bedtime routine that takes about an
hour to complete. He has many requests before he finally lays
down, and his mom lays down with him until he falls asleep. He
sleeps from 9:00pm until 7:00am. He comes to his parentsbedroom about twice a month.
Appetite: He has to eat the same thing for lunch each day: a
turkey sandwich with cheese, no crusts. He always eats the
bread first, then meat, then cheese. He is a very picky eater.
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Other pertinents
Past Medical History: Full term, uncomplicated pregnancy anddelivery. No chronic medical illnesses. No surgical history.Immunizations UTD. Had a rash with amoxicillin this year afterhe was treated for strep throat.
Developmental History: no language delay. Met all milestones ontime.
Family History: Mom has anxiety treated with Zoloft and Xanax.She was diagnosed in her 20s after she had anxiety that kept
her in bed for weeks. Extended family members havedepression and anxiety disorders, including OCD. No familyhistory of bipolar disorder, suicide attempt or suicidecompletion, or psychosis/schizophrenia.
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Should J.J.s family delay
kindergarten? There is almost never an awesome reason to keep a child out
of school
Kindergarten provides socialization, learning, and school
readiness activities, which is often what an immature childneeds
Assessment and intervention through the school system: the
earlier, the better!
Preliminary data suggest that old-for-grade students have
increased rates of behavioral problems (particularly as
adolescents)
Specifically in Utah, there are age limits for student athletes (no
19 year olds)
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And, what does immature mean,
anyway? When parents are concerned and are considering holding their
child back, use this as a springboard concern!
What concerns them about their child?
The immature childs parents may have identified something
that may need evaluation, intervention, or school
accommodations
Rule out developmental delay, identify the child at risk forattention or learning problems
Balance appropriate concern with a healthy respect for
individual variation- there is a substantial variation at this age!
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Developmental Tasks Facing
Children at School Entry Separation
Increasing individualization
Integration of cognitive skills
Ability to form relationships with other children and adults
Ability to participate in group activities and follow rules and
directions
Gradual formation of a sense of self or identity, both inside and
outside the family environment
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Social-Emotional Skills at School
Entry
Self-regulation
Executive function: planning, organizing, following directions
CapacCapacity to be responsive to teachers
Ability to master new experiences
Play skills (taking turns, sharing)
ity to tolerate separations from caregivers
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Identifying the Child at Risk for
Learning Disabilities
Use your Reach Out and Read
book to assess early reading skills
The most common learning disabilityis dyslexia, or a specific problem inreading
Targeted questions and
developmental tasks that assess earlyreading skills:
Letter identification
Letter-sound association
Verbal memory (recalling asentence or story that was just told)
Rapid naming (rapidly naming acontinuous series of familiarobjects)
Expressive vocabulary or wordretrieval (naming single picturedobjects)
Conservative estimates of the
prevalence of learning
disabilities is 7% of school agechildren
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Assessing Attention and Learning
Digit span: a five year old
should be able to recall 4
numbers
Serial commands: a five yearold should be able to perform at
least 4 directions
How does the child behave in
your office? How does s/he
respond to your exam? Created by a 5 year old while I
interviewed his mom. Does this
child have ADHD?
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Copying figures: a review
Circle: 3 years
Cross: 4 years
Square: 5 years
Triangle: 6 years
Diamond: 7 years
Present the figures for the child
to copy (dont demonstrate how
to draw them!)
Tripod grasp of the pencil orcrayon should be seen at age 5
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Drawing Interview
Ask the child to draw a person while the clinician interviews the
parents (Please draw a picture of a boy or a girl.)
The drawing interview consists of questions you ask the child
to engage him/her in conversation:
Do you think it is a picture of a boy or a girl?
Tell me a make-believe story about this boy or girl.
If no response, restate the above: tell me something about this boy
or girl
What else is s/he doing?
When the child stops, repeat what was said. Add, what else
happens to the boy/girl?
This is fun, but dont over interpret the drawing. This is not an inkblot test.
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So, does J.J. have Obsessive-
Compulsive Disorder, or what?
J.J.s mother feels that his preferences do not particularly interfere
with the familys functioning.
His dad finds his bedtime routine somewhat laborious, but the family is
not particularly interested in changing J.J.s behavior at this point.
J.J.s preschool teachers have not identified any behavior problems,
and it appears that he is functioning well in preschool.
J.J. is able to meet expected developmental norms during your
assessment.
What is your anticipatory guidance?
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References
Dixon and Stein, Encounters with Children. Fourth ed. Mosby-Elsevier, 2006.
Dworkin, PH. School readiness. Curr Opin Pediatrics. 3:786,
1991.
Sturner, R, and B Howard. Preschool development I:
Communicative and motor aspects. Pediatrics in Review.
18:291, 1997.