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What's Up With Weird Doctor Tests?

A look at the why's and how's of pediactric visits

Much of what we doctors do during an exam needs no explanation. A bonk on the knee? Reflexes are A-OK. A check of the heartbeat to (shocker!) check the heart. But why might I ask a child to draw a cross? And what am I really interested in when I ask what she had for breakfast? (Hint: It's not just about food.) Kids are moving targets of growth and development, so we sometimes have to delve into a fancier bag of tricks to assess what's going on (or not). Call it happy stealth or clinical cunning, but part of the job of a pediatrician is to start our exams at hello and, as much as possible, to investigate our little charges without them feeling investigated.

When I enter an exam room, I have my perception antennae in full operation. I'm gathering information as I meet and greet a parent and child: How does the kid handle the transition of my coming in (temperament, anxiety)? Does he check in with his parent as I greet them (connectedness, confidence)? What does he say to me and how does it sound (speech, social skills)? A 5-year-old boy recently in for a checkup was as quiet as a church mouse when I entered. After a few minutes of us comparing which of his feet was smellier (I didn't inhale), he warmed up and started speaking animatedly about his bike. The point? He was showing age-appropriate shyness. And I got a glimpse of his personality: slow to warm, then away he goes. Good to know for future discussions. And I'll remember to ask about his bike too.

Talking Points

By the second birthday, parents have become accustomed to answering all of the questions about their child's history. So I get some surprised looks when I turn to a child and ask him directly: "What's in your sippy cup?" A seemingly sociable question is something more. I'm evaluating the child's social skills and, more specifically, his language skills. (I might also get a glimpse of his beverage profile.) There are simple guidelines for gauging language skills. (Of course, children vary widely — no need to worry.) At age 2, a child should consistently produce utterances of two words ("Go outside!"), and half of what he says should be understandable to a stranger. At 3, three-fourths of a child's speech should be clear in three-word sentences. By 4, four-word phrases (or longer) are typical ("I want to go there") and should be 100 percent (four-fourths) intelligible. For school-age children, it's important to see if they can tell a story, recall information about their school and friends, and ask those big questions, like "Why do stars twinkle?" Very often, parents (like me with my kids) report that their children relate stuff at the doctor's office in a way they rarely do at home. ("Really, you want to work at the aquarium?" Pediatrics as open-mike night.)

Portrait of the Artist

While talking with parents, I might give a child some crayons and paper to scribble on or ask him to copy a shape. It's a nice distraction, but it can also give me important info. Some patients take on such missions with gusto, a testament to their cooperative spirit and ability to follow directions. More to the point, this task can demonstrate a child's fine-motor skills and be an indicator of school readiness (scribbling is a learned art!). Most children will scrawl away by 15 months (kids not given writing instruments as often may focus more on the smell or taste). Vertical or circling movements typically show up by age 2. Then it gets technical: Children can usually copy a circle by 3 years, a cross by 4 years, a square by 41⁄2, and a triangle by 5. Before you send your child to a Kaplan shapes course, though, understand I share this to enlighten, not to spur you to coach your kids. Free doodling is a sacred, valuable pastime. These tests merely help gauge where a child is compared with his peers; some kids may just need more time. One doodle does not a diagnosis make.

How a kid responds when I ask him to draw a person tells me a bit about his cognitive function, motor planning, and social and emotional inner life. Does he struggle with the task? Does he toss the paper and refuse to try? Or does he barrel in and give it his best shot? We "score" the final product thusly: Taking a base age of 3 years, a child earns a quarter year for each feature. So a child who draws a man with eyes, nose, mouth, and legs has made a drawing with an age equivalent of 4 years.

Simon Says . . .

There are a number of goofy-looking things we might make kids do to get a check on the brain and central nervous system. (They're also good for breaking up the interminable adult chatter.) Take the evaluation for dysdiadochokinesia, which looks at the workings of the posterior cerebellum. The condition manifests itself as an inability to perform rapid, alternating movements, so I'll ask a child how he'd turn a doorknob or screw in a lightbulb. Bonus if the office lights need changing.

Standing still with eyes closed is an indicator of balance and brain stem regulation, and holding hands out while doing so gives information on how kids sense their position in space (proprioception, to be technical). Plus, it looks zombie hilarious.

To the uninitiated, a cranial nerve exam can look like an ugly face smackdown. Cranial nerves wire our senses and control our facial muscles. I'll ask a kid to furrow his brow, shut his eyes super tight, grin like a pumpkin, or shake his head. All in the name of knowledge.

Why does all this matter?

In the neurodevelopmental assessment of children, pixels make a picture. A single test or result cannot characterize the entirety of a child. When I witness a child's growth and mastery of new abilities, in the context of his environment and medical history, that is when I can begin to make an assessment. But it ain't all investigative. A pediatrician relies on the brief time with a family to get to know how they work and how the child functions within that family. Developing a rapport with child and parent is essential, especially for children approaching adolescence. Some of what we do is to assess the health and well-being of your offspring. Other times, we reserve the right to get to know them better, do a little bonding, and perhaps let our inner 5-year-old out in the process.

Turbo Small Talk


Sneaky? Maybe. Here's how I get the good stuff.

Q "What color is your toothbrush?"
Kids proudly display their knowledge of colors while I find out if they brush and whether they are invested enough in dental hygiene to know their toothbrush color.

Q "How much screen time do you get each day?"
Asking "How many hours of TV do you watch?" may not capture all the time spent texting or playing online, kicking virtual butt while his own gets bigger. Research has shown a close association between more hours in front of the TV, computer, or video games and increased rates of obesity.

Q "Where do you watch TV?"
A television in a child's bedroom can be a source of sleep problems.

Q "Who is your best friend?"
Most kids will rattle off a few names without a blink. Others might hesitate or look sad, precipitating a discussion on shyness or difficulties making friends.

Q "Where do you live?"
I get a sense if a kid knows his street/town/ state and, for safety reasons, whether he knows his address and parents' phone numbers.

About the Doctor:
Jack Maypole is a pediatrician at Boston Medical Center and director of pediatrics at the South End Community Health Center. He's wondering: What's in your sippy cup?

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