HEALTH SUPERVISION VISIT GUIDELINES SCHOOL-AGED CHILD SUZANNE LEFEVRE MD

HEALTH SUPERVISION HEALTH SUPERVISION VISIT GUIDELINESVISIT GUIDELINES

SCHOOL-AGED CHILDSCHOOL-AGED CHILD

SUZANNE LEFEVRE MDSUZANNE LEFEVRE MD

GENERAL APPROACH TO THE WELL GENERAL APPROACH TO THE WELL CHILD VISITCHILD VISIT

INTERVAL HISTORY/OBSERVATIONINTERVAL HISTORY/OBSERVATIONNUTRITIONNUTRITIONELIMINATIONELIMINATIONSLEEP PATTERNSSLEEP PATTERNSDEVELOPMENT/BEHAVIOR/SCHOOL DEVELOPMENT/BEHAVIOR/SCHOOL PERFORMANCEPERFORMANCEPHYSICAL EXAMPHYSICAL EXAMANTICIPATORY GUIDANCEANTICIPATORY GUIDANCEDISEASE PREVENTION/HEALTH DISEASE PREVENTION/HEALTH PROMOTION AND INJURY PREVENTIONPROMOTION AND INJURY PREVENTION

4 YEAR OLD VISIT4 YEAR OLD VISIT

Interval history/ Interview with behavioral observationsInterval history/ Interview with behavioral observations

– Child: How are you? How old are you? Do you go to Child: How are you? How old are you? Do you go to school? Where?school? Where?

– Parent: Have there been any illnesses, hospitalizations Parent: Have there been any illnesses, hospitalizations or ED visits since our last visit? How is your child doing or ED visits since our last visit? How is your child doing in pre-school or child care? Do you have any particular in pre-school or child care? Do you have any particular concerns you’d like to discuss?concerns you’d like to discuss?

4 Year Old Visit4 Year Old VisitNutritionNutrition

– Child: What do you like to eat?Child: What do you like to eat?– Parent:: Do you have any concerns about your child’s eating habits?Parent:: Do you have any concerns about your child’s eating habits?– Describe a typical dinner in your home?Describe a typical dinner in your home?

Anticipatory Guidance:Anticipatory Guidance:– Kids age 4-8 need 800mg of Calcium per day; one 8 oz glass of milk contains 300mgKids age 4-8 need 800mg of Calcium per day; one 8 oz glass of milk contains 300mg– Recommend limiting juice to no more than 6 oz of 100% fruit juice.Recommend limiting juice to no more than 6 oz of 100% fruit juice.– Food jags (favoring 1 or 2 foods) and picky eating are normal behaviors.Food jags (favoring 1 or 2 foods) and picky eating are normal behaviors.– Explain the growth chartExplain the growth chart

Suggestions for picky eatersSuggestions for picky eaters– Offer small portions first, then second helpingsOffer small portions first, then second helpings– Try to create a pleasant atmosphere at meal timeTry to create a pleasant atmosphere at meal time– Include child in conversation at the dinner tableInclude child in conversation at the dinner table– Offer a variety of foods and repeat themOffer a variety of foods and repeat them


EliminationElimination– Parent:: Does the child use the toilet for urination and having Parent:: Does the child use the toilet for urination and having

bowel movements?bowel movements?– Have you noticed any discomfort when the child has a bowel Have you noticed any discomfort when the child has a bowel

movement?movement?

By age 4, 95% of children are bowel trainedBy age 4, 95% of children are bowel trained

90% are dry during the day90% are dry during the day

75% are dry at night75% are dry at night

– Anticipatory GuidanceAnticipatory Guidance

No specific interventions are warranted for night time wetting No specific interventions are warranted for night time wetting because it’s so common at this age.because it’s so common at this age.

Stress importance of balanced diet in preventing constipationStress importance of balanced diet in preventing constipation

4 Year Old Visit4 Year Old Visit

Sleep PatternsSleep Patterns

– Child: Where do you sleep?Child: Where do you sleep?– Parent:: How does your child get to sleep at night? Does your Parent:: How does your child get to sleep at night? Does your

child nap? Does your child experience nightmares, night terrors, child nap? Does your child experience nightmares, night terrors, or sleepwalking?or sleepwalking?

– NightmaresNightmares are common and involve vivid, scary or exciting are common and involve vivid, scary or exciting events which are easily recalled by the child upon awakening. events which are easily recalled by the child upon awakening.

– Night terrorsNight terrors are common particularly in boys ages 5-7 but can are common particularly in boys ages 5-7 but can

see as early as 4. They occur in 1 – 3% of children and are see as early as 4. They occur in 1 – 3% of children and are usually short lived. Characterized by sudden onset, usually usually short lived. Characterized by sudden onset, usually between midnight and 2:00am during stage 3 or 4 of slow wave between midnight and 2:00am during stage 3 or 4 of slow wave sleep. The child screams, appears frightened, tachycardic and sleep. The child screams, appears frightened, tachycardic and may hyperventilate. Child my thrash violently, there is little or no may hyperventilate. Child my thrash violently, there is little or no verbalization and cannot be consoled. Sleep follows in a few verbalization and cannot be consoled. Sleep follows in a few minutes and there is total amnesia of the event upon waking.minutes and there is total amnesia of the event upon waking.



– Anticipatory guidanceAnticipatory guidanceEncourage children to sleep in their own beds if Encourage children to sleep in their own beds if that is compatible with the family’s culturethat is compatible with the family’s culture

Create a calm bedtime ritual like reading or story Create a calm bedtime ritual like reading or story tellingtelling

Reassure parents that nightmares and night terrors Reassure parents that nightmares and night terrors are common are common


Development and BehaviorDevelopment and Behavior– Child: What sort of things are you good at doing? Can you get yourself Child: What sort of things are you good at doing? Can you get yourself

dressed?dressed?

– Parent: What skills do you expect of a 4 year old that your child cannot Parent: What skills do you expect of a 4 year old that your child cannot perform?perform?

– Ages and Stages QuestionnaireAges and Stages Questionnaire– MilestonesMilestones

Gross motor: Pedals tricycle, hops on one foot, balances on one foot, walks up and Gross motor: Pedals tricycle, hops on one foot, balances on one foot, walks up and down stairs with alternating gatedown stairs with alternating gate

Fine motor: Draws a circle and cross, draws a person with 3 to 6 body parts, cuts with Fine motor: Draws a circle and cross, draws a person with 3 to 6 body parts, cuts with scissorsscissors

Cognitive skills: complex pretend play, may have imaginary friend, recognizes some Cognitive skills: complex pretend play, may have imaginary friend, recognizes some of the alphabetof the alphabet

Language skills: Uses full sentences of at least 6 words, 100% intelligibleLanguage skills: Uses full sentences of at least 6 words, 100% intelligible

Social skills: engages in interactive play, able to share, can play a board or card Social skills: engages in interactive play, able to share, can play a board or card game.game.

Self-help skills: Able to put on shirt, pants, socks, able to button and zip; able to brush Self-help skills: Able to put on shirt, pants, socks, able to button and zip; able to brush teeth; toilet trainedteeth; toilet trained


Physical ExamPhysical Exam

– HeightHeight– WeightWeight– Blood PressureBlood Pressure– General physical exam to includeGeneral physical exam to include

Visual acuity- objectiveVisual acuity- objective

Hearing screen- objectiveHearing screen- objective

Check for obvious dental cariesCheck for obvious dental caries

Check gait, spine and extremitiesCheck gait, spine and extremities

Be alert for signs of abuseBe alert for signs of abuse– Screening: Hemoglobin if at risk for anemia (i.e., special health Screening: Hemoglobin if at risk for anemia (i.e., special health

needs, low iron diet or environmental factorsneeds, low iron diet or environmental factors– ImmunizationsImmunizations: : See current recommended schedule (DTaP, See current recommended schedule (DTaP,

IPV, MMRV)IPV, MMRV)

4 Year Old Visit 4 Year Old Visit Injury PreventionInjury Prevention

Toys should be age Toys should be age appropriateappropriate

Falls are commonFalls are common

Keep dangerous Keep dangerous materials out of reach; materials out of reach; matches, tools and matches, tools and poisonspoisons

Helmets for tricycle safetyHelmets for tricycle safety

Car seats and seat beltsCar seats and seat belts

Start booster seat at Start booster seat at 40lbs and 40 inches 40lbs and 40 inches talltall

Adult supervision near Adult supervision near water, consider swimming water, consider swimming lessonslessonsGood touch/bad touchGood touch/bad touchCareful around strange Careful around strange dogsdogsGun safety: AAP Gun safety: AAP recommends that they be recommends that they be removed from the homeremoved from the homeTeach child how to dial Teach child how to dial “911”“911”UV protectionUV protection


Close the visitClose the visit

– Are there any issues that we missed?Are there any issues that we missed?– Set time and reason for next appointmentSet time and reason for next appointment


Interval History/ Interview with Behavioral ObservationsInterval History/ Interview with Behavioral Observations

– O.K. to talk to child alone for a few minutes. As the child O.K. to talk to child alone for a few minutes. As the child grows older the time period gradually increases. This is grows older the time period gradually increases. This is patient and family dependentpatient and family dependent

– Child: Have you been sick since I saw you last? How many Child: Have you been sick since I saw you last? How many brothers and sisters do you have?brothers and sisters do you have?

– Parent: How is your family doing? Have there been any Parent: How is your family doing? Have there been any changes in the family?changes in the family?


NutritionNutrition

– Child: What are your favorite snacks?Child: What are your favorite snacks?

– Parent: Do you have any concerns about your child’s weight?Parent: Do you have any concerns about your child’s weight?


Same as the 4 year old visitSame as the 4 year old visit

Discuss healthy snackingDiscuss healthy snacking


EliminationElimination– Child: do you have any problems with bowel movements Child: do you have any problems with bowel movements

(“poop”) or urinating (“pee”)?(“poop”) or urinating (“pee”)?– Parent: Does your child wet the bed at night?Parent: Does your child wet the bed at night?

At age 5 approximately 20% of children wet the bed at least At age 5 approximately 20% of children wet the bed at least monthly.monthly.

Approximately 5% of boys and less than 1% of girls wet the bed Approximately 5% of boys and less than 1% of girls wet the bed nightlynightly


No specific interventions are warranted for night time wetting No specific interventions are warranted for night time wetting at this age.at this age.



– Same as 4 year old visitSame as 4 year old visit


Development and BehaviorDevelopment and Behavior

– Child: Can you write your name?Child: Can you write your name?– Parent: Can your child tie his shoes? Is your child comfortable in Parent: Can your child tie his shoes? Is your child comfortable in

speaking to others?speaking to others?

– ASQ (Ages and Stages Questionnaire)ASQ (Ages and Stages Questionnaire)

– MilestonesMilestonesGross motor: balances on one foot, hops, skipsGross motor: balances on one foot, hops, skipsFine motor: able to tie a knot, has mature pencil grasp, draws a person Fine motor: able to tie a knot, has mature pencil grasp, draws a person with at least 6 body parts, able to copy squares and triangles.with at least 6 body parts, able to copy squares and triangles.Language: Names at least 4 colors, counts to 10, tells a simple story Language: Names at least 4 colors, counts to 10, tells a simple story using full sentences, appropriate tenses, pronouns.using full sentences, appropriate tenses, pronouns.Social skills: follows simple directions, able to listen and attend, dresses Social skills: follows simple directions, able to listen and attend, dresses and undresses with minimal assistance.and undresses with minimal assistance.


Physical ExamPhysical Exam– Same as the 4 year old visitSame as the 4 year old visit

ScreeningScreening– UrinalysisUrinalysis– Other screening as indicated by risk: lead, Other screening as indicated by risk: lead,

hemoglobin, PPDhemoglobin, PPD

5 Year Old Visit5 Year Old VisitAnticipatory GuidanceAnticipatory Guidance

Injury Prevention/Health Promotion Injury Prevention/Health Promotion

– Fire safety (alarms, Fire safety (alarms, fire escapes, home fire escapes, home plan for emergencies)plan for emergencies)

– Dealing with strangersDealing with strangers– Discourage skate Discourage skate

boarding or in-line boarding or in-line skating unless skating unless helmets, wrist, elbow helmets, wrist, elbow and knee pads are and knee pads are usedused

– Violence preventionViolence prevention– Pedestrian and bicycle Pedestrian and bicycle

safetysafety

– Regular exercise/family Regular exercise/family activitiesactivities

– Brush teeth at least 2 Brush teeth at least 2 times per day. See times per day. See dentist 2 times per year.dentist 2 times per year.

– TV viewing should be TV viewing should be limited and monitoredlimited and monitored

– Encourage interaction Encourage interaction with other kids, with other kids, grandparents and adultsgrandparents and adults

– Spend time playing with Spend time playing with child every daychild every day

6-7 Year Old Visit6-7 Year Old Visit

Interval History/Interview with Behavioral Interval History/Interview with Behavioral ObservationsObservations

Child: What grade are you in? Have you been sick Child: What grade are you in? Have you been sick since our last visit? Any broken bones or stitches?since our last visit? Any broken bones or stitches?

Parent: Have there been any family crisis or stressors? Parent: Have there been any family crisis or stressors? Is your child on any medications?Is your child on any medications?

6 – 7 Year Old Visit6 – 7 Year Old Visit

NutritionNutrition

– Child: Do you eat fruits and Child: Do you eat fruits and vegetables?vegetables?

– Parent: What does your child Parent: What does your child eat for protein? How much eat for protein? How much milk does your child drink?milk does your child drink?

– Anticipatory Guidance: Anticipatory Guidance: Continue to promote well-Continue to promote well-balanced diet.balanced diet.Avoid junk foodsAvoid junk foodsConsider need for Consider need for vitamins, iron supplementsvitamins, iron supplementsEncourage regular Encourage regular exerciseexercise

EliminationElimination

– Child: Do you have a Child: Do you have a bowel movement every bowel movement every day? Is it hard or soft? day? Is it hard or soft? Does it hurt?Does it hurt?

– Parent: Does your child Parent: Does your child have problems with day have problems with day time wetting, night time time wetting, night time wetting or soiling?wetting or soiling?

– Anticipatory Anticipatory GuidanceGuidance

By age 6 only 10% of By age 6 only 10% of children will wet the bedchildren will wet the bedIf problems are If problems are identified, enuresis, identified, enuresis, constipation and constipation and encopresis.encopresis.


Development and BehaviorDevelopment and Behavior– Child: Can you ride a bike? Show me your left hand?Child: Can you ride a bike? Show me your left hand?

– Parent:: How would you evaluate your child’s abilities in sports? Parent:: How would you evaluate your child’s abilities in sports? How are your child’s abilities to draw and write?How are your child’s abilities to draw and write?

– Milestones:Milestones:

Gross motor: skipGross motor: skip

Fine motor: Draw a picture of a person with 8 to 10 featuresFine motor: Draw a picture of a person with 8 to 10 features

Language/Cognitive: Recount a personal story about a Language/Cognitive: Recount a personal story about a recent event, count to 20recent event, count to 20


Physical Exam: Physical Exam: – Same as 5 year oldSame as 5 year old

Screening: Screening: – Same as 5 year oldSame as 5 year old

Injury Prevention/Health promotion: Injury Prevention/Health promotion: – Same as 5 year oldSame as 5 year old

School ReadinessSchool Readiness

Years from 3 to 6 are historically called “preschool” because Years from 3 to 6 are historically called “preschool” because of their importance for preparing the child for the tasks of of their importance for preparing the child for the tasks of schoolschool

Determine any parental concerns about school readiness by Determine any parental concerns about school readiness by asking trigger questionsasking trigger questions– How does your child feel about going to school?How does your child feel about going to school?– How are you feeling about John/Jane going to school?How are you feeling about John/Jane going to school?– When you were John’s/Jane’s age, did you enjoy school?When you were John’s/Jane’s age, did you enjoy school?– How did John/Jane do in preschool?How did John/Jane do in preschool?– Is there anything you would like checked before he/she goes to Is there anything you would like checked before he/she goes to

school?school?– Is there anything the school or teacher should know?Is there anything the school or teacher should know?

School ReadinessSchool ReadinessParental concerns regarding developmental milestonesParental concerns regarding developmental milestones

Communication/LanguageCommunication/Language– Knowledge of letters, Knowledge of letters,

words and symbolswords and symbols– Ability to recognize letters Ability to recognize letters

and numbersand numbers– Articulate speechArticulate speech

Behavioral/Emotional SkillsBehavioral/Emotional Skills– Ability to take another Ability to take another

persons point of view and persons point of view and follow rulesfollow rules

– Separation anxietySeparation anxiety– Social shynessSocial shyness– Temper tantrums and Temper tantrums and

tendency to be aggressive tendency to be aggressive when fearful are indicators when fearful are indicators of emotional immaturityof emotional immaturity

Gross motor/Fine motorGross motor/Fine motor– Ability to print letters and Ability to print letters and

numbersnumbers– Good gross motor Good gross motor

coordination can provide coordination can provide important status with peers important status with peers and is a source of self-and is a source of self-esteem through athletics. esteem through athletics. This is least predictive of This is least predictive of school achievement when school achievement when compared with other areas compared with other areas of development.of development.

– Physical size and staturePhysical size and stature

Developmental milestones necessary for Developmental milestones necessary for Elementary School SuccessElementary School Success

CognitiveCognitive

– Long term memory, storage and recallLong term memory, storage and recallThis is the ability to acquire skills that are “automatic”This is the ability to acquire skills that are “automatic”Deficit: Delayed mastery of the alphabet, slow handwriting and the Deficit: Delayed mastery of the alphabet, slow handwriting and the inability to progress past basic mathematicsinability to progress past basic mathematics

– Selective AttentionSelective AttentionAbility to attend to important stimuli and ignore distractionsAbility to attend to important stimuli and ignore distractionsDeficit: Difficulty following multi-step instructions, completing Deficit: Difficulty following multi-step instructions, completing assignments and behaving wellassignments and behaving well

– SequencingSequencingAbility to remember things in orderAbility to remember things in orderDeficit: Difficulty organizing assignments, planning, spelling and telling Deficit: Difficulty organizing assignments, planning, spelling and telling timetime

Levine MD: Developmental-Behavioral Pediatrics. Nelsons 2004Levine MD: Developmental-Behavioral Pediatrics. Nelsons 2004

Developmental Milestones necessary for Developmental Milestones necessary for Elementary School SuccessElementary School Success

PerceptionPerception

– Visual AnalysisVisual AnalysisAbility to break a complex figure into components and Ability to break a complex figure into components and understand spatial relationshipsunderstand spatial relationshipsDeficit: Persistent letter confusion (between b,d and g), Deficit: Persistent letter confusion (between b,d and g), difficulty with basic reading and writing and limited sight difficulty with basic reading and writing and limited sight vocabularyvocabulary

– Proprioception and fine motor controlProprioception and fine motor controlAbility to obtain information about body position by feel and Ability to obtain information about body position by feel and unconsciously program complex movementsunconsciously program complex movementsDeficit: Poor handwriting often with overly tight pencil grasp, Deficit: Poor handwriting often with overly tight pencil grasp, difficulty with timed tasksdifficulty with timed tasks


Developmental Milestones necessary for Developmental Milestones necessary for Elementary School SuccessElementary School Success

LanguageLanguage

– ReceptiveReceptiveAbility to comprehend constructive function words like: if, when, only, Ability to comprehend constructive function words like: if, when, only, except. Ability to understand nuances of speech and extended except. Ability to understand nuances of speech and extended blocks of language (e.g. paragraphs)blocks of language (e.g. paragraphs)Deficit: Difficulty following directions, wandering during lessons and Deficit: Difficulty following directions, wandering during lessons and stories, problems with reading comprehension, problems with peer stories, problems with reading comprehension, problems with peer relationshipsrelationships

– ExpressiveExpressiveAbility to recall required words effortlessly (word finding), to control Ability to recall required words effortlessly (word finding), to control meanings by varying position and word endings, to construct meanings by varying position and word endings, to construct meaningful paragraphs and storiesmeaningful paragraphs and storiesDeficit: Difficulty expressing feelings and using words for self-Deficit: Difficulty expressing feelings and using words for self-defense, with resulting frustration and physical acting out; struggling defense, with resulting frustration and physical acting out; struggling during “circle time” and language based subjectsduring “circle time” and language based subjects


ReferencesReferences

Bright Futures, Health Supervision III Bright Futures, Health Supervision III Guidelines 2008 AAP PublicationGuidelines 2008 AAP Publication

Caring for your Baby and Young Child Caring for your Baby and Young Child AAP Publication AAP Publication

Nelsons Textbook of Pediatrics 2004Nelsons Textbook of Pediatrics 2004

Pediatrics: A Primary Care Approach,Pediatrics: A Primary Care Approach,Carol Berkowitz, MD, FAAP, 2008Carol Berkowitz, MD, FAAP, 2008

General Approach to the Well Child VisitGeneral Approach to the Well Child Visit

Interval History/Behavioral ObservationInterval History/Behavioral Observation

NutritionNutrition

EliminationElimination


Development/Behavior/School PerformanceDevelopment/Behavior/School Performance

Physical ExamPhysical Exam

Anticipatory GuidanceAnticipatory Guidance

Disease Prevention, Health Promotion, Injury PreventionDisease Prevention, Health Promotion, Injury Prevention


Interval History/Interview with Behavioral ObservationsInterval History/Interview with Behavioral Observations

– Child: How are things going?Child: How are things going?– Parent: Have there been any changes in your child’s health?Parent: Have there been any changes in your child’s health?

– Middle childhood is marked by considerable development in academic skills, Middle childhood is marked by considerable development in academic skills, physical abilities, social interactions and emotional regulation. School physical abilities, social interactions and emotional regulation. School success and home life are both important for self-esteem.success and home life are both important for self-esteem.

NutritionNutrition

– Child: How is your appetite? What do you eat for breakfast?Child: How is your appetite? What do you eat for breakfast?– Parent: How is your child’s appetite?Parent: How is your child’s appetite?

– Encourage child to eat breakfast dailyEncourage child to eat breakfast daily– Reinforce need for balanced diet avoiding junk foodReinforce need for balanced diet avoiding junk food– With a balanced diet and exercise there should be no need for dietingWith a balanced diet and exercise there should be no need for dieting

8 – 9 Year Old Visit8 – 9 Year Old VisitEliminationElimination

– Child: How often do you have bowel movements?Child: How often do you have bowel movements?– Parent: Do you have any concerns about your child’s toilet habits?Parent: Do you have any concerns about your child’s toilet habits?

– Enuresis: Defined as normal voiding that occurs at an inappropriate Enuresis: Defined as normal voiding that occurs at an inappropriate time or involuntarily in a socially unacceptable setting. time or involuntarily in a socially unacceptable setting.

Defined as occurring at least 2 per week for at least 3 consecutive monthsDefined as occurring at least 2 per week for at least 3 consecutive monthsDiagnosis is reserved for girls older than 5 and boys older than 6Diagnosis is reserved for girls older than 5 and boys older than 6Diurnal enuresis occurs during the dayDiurnal enuresis occurs during the dayNocturnal enuresis occurs at nightNocturnal enuresis occurs at nightPrimary enuresis refers to kids who have never achieved sustained Primary enuresis refers to kids who have never achieved sustained drynessdrynessSecondary enuresis refers to kids whose urinary incontinence occurs after Secondary enuresis refers to kids whose urinary incontinence occurs after 3 to 6 months of dryness3 to 6 months of dryness75% to 80% of kids with enuresis have primary enuresis75% to 80% of kids with enuresis have primary enuresisIncidence of secondary enuresis increases with age and makes up 50% by Incidence of secondary enuresis increases with age and makes up 50% by age 12age 12Causes of primary enuresis include faulty toilet training, maturational Causes of primary enuresis include faulty toilet training, maturational delay, small bladder capacity, sleep disorders, nocturnal polyuriadelay, small bladder capacity, sleep disorders, nocturnal polyuriaCauses of secondary enuresis include UTI’s, diabetes mellitus and Causes of secondary enuresis include UTI’s, diabetes mellitus and insipidus, genitourinary anomalies, seizure disorder, medication useinsipidus, genitourinary anomalies, seizure disorder, medication use


Sleep PatternsSleep Patterns– Child: What time do you go to bed at night? How many hours do you Child: What time do you go to bed at night? How many hours do you

sleep on a school night?sleep on a school night?

– Children age 8 frequently sleep 9 to 12 hours per night.Children age 8 frequently sleep 9 to 12 hours per night.

SchoolSchool– Child: What subjects do you like? What do you think about your Child: What subjects do you like? What do you think about your

grades?grades?

– Parent: How are your child’s reading and writing skills? What did you Parent: How are your child’s reading and writing skills? What did you learn at the parent-teacher conference?learn at the parent-teacher conference?

– If school failure is suspected discuss need for comprehensive approach If school failure is suspected discuss need for comprehensive approach involving parents, school and pediatrician.involving parents, school and pediatrician.


Development and BehaviorDevelopment and Behavior

– Child: What do you like to do for fun? How many hours each day do Child: What do you like to do for fun? How many hours each day do you watch T.V?you watch T.V?

– Parent: What are your expectations for your child in terms of sports and Parent: What are your expectations for your child in terms of sports and extracurricular activities? How does your child get along with friends extracurricular activities? How does your child get along with friends and peers at school?and peers at school?

– Parents should encourage peer play outside the home, i.e. clubs, Parents should encourage peer play outside the home, i.e. clubs, camps or athletic teams.camps or athletic teams.

– Parents should consider giving an allowance to encourage Parents should consider giving an allowance to encourage independence and responsibility.independence and responsibility.

– Recommend fair, understandable rules about chores, T.V., outside Recommend fair, understandable rules about chores, T.V., outside activities, homework and bedtime.activities, homework and bedtime.

– Encourage follow through with stated consequences when rules are Encourage follow through with stated consequences when rules are broken.broken.

– Consider discussing puberty.Consider discussing puberty.


Physical ExamPhysical Exam– HeightHeight– WeightWeight– Blood PressureBlood Pressure– Look for signs of pubertyLook for signs of puberty

ScreeningScreening– Hemoglobin, PPD if high riskHemoglobin, PPD if high risk

Injury Prevention/ Health promotion/ Disease PreventionInjury Prevention/ Health promotion/ Disease Prevention– Discuss participation in team sports where emphasis is fun and not Discuss participation in team sports where emphasis is fun and not

winningwinning– For those children that don’t like team sports, encourage individual For those children that don’t like team sports, encourage individual

sports like swimming, tennis, dance or gymnasticssports like swimming, tennis, dance or gymnastics– Trampoline use should be discouragedTrampoline use should be discouraged– Children can learn CPR at this ageChildren can learn CPR at this age– Gun SafetyGun Safety– Smoke detectors in the homeSmoke detectors in the home


Interval History/ Interview with Behavioral ObservationsInterval History/ Interview with Behavioral Observations

– Speak to child alone during some portion of the visitSpeak to child alone during some portion of the visit

– Explain confidentiality to the child and parentsExplain confidentiality to the child and parents

– At this age peer groups become an increasingly important influence on At this age peer groups become an increasingly important influence on style, attitudes and values. They may begin risk-taking behaviors such style, attitudes and values. They may begin risk-taking behaviors such as cigarette smoking or drinking alcohol.as cigarette smoking or drinking alcohol.

NutritionNutrition

– Child: What is meant by a well balanced diet?Child: What is meant by a well balanced diet?

– Parent: Is there a history of elevated cholesterol in your family?Parent: Is there a history of elevated cholesterol in your family?

– Encourage child to eat breakfast before schoolEncourage child to eat breakfast before school

– Encourage regular exerciseEncourage regular exercise

– Advise parent and child about adequate hydration during warm climate Advise parent and child about adequate hydration during warm climate sports or outdoor activitiessports or outdoor activities

10 – 11 Year Old Visit10 – 11 Year Old VisitEliminationElimination– Child: Do you experience pain or burning with urination?Child: Do you experience pain or burning with urination?

Sleep PatternsSleep Patterns– Child: How do you feel when you wake up in the morning?Child: How do you feel when you wake up in the morning?– Parent: How much sleep does your child get at night?Parent: How much sleep does your child get at night?– Children this age should still get at least 9 hours of sleep per nightChildren this age should still get at least 9 hours of sleep per night

Development/ BehaviorDevelopment/ Behavior– Child: Where do you spend your time after school?Child: Where do you spend your time after school?– Parent: What are the most enjoyable activities you do together? What Parent: What are the most enjoyable activities you do together? What

activities are most likely to cause friction or problems?activities are most likely to cause friction or problems?– Age 10 is a prime year for sports competition. Year round participation Age 10 is a prime year for sports competition. Year round participation

in multiple sports my reduce over-use injuries of same muscle groups.in multiple sports my reduce over-use injuries of same muscle groups.– Strength training is appropriate with proper supervision.Strength training is appropriate with proper supervision.– Parents should discuss tobacco, alcohol and illicit drug use.Parents should discuss tobacco, alcohol and illicit drug use.– Encourage parents to prepare girls for menarche.Encourage parents to prepare girls for menarche.

10 – 11 Year Old Visit10 – 11 Year Old VisitPhysical ExamPhysical Exam– HeightHeight

– WeightWeight

– Blood PressureBlood Pressure

– Make sure to include assessment for scoliosis, Tanner staging and Make sure to include assessment for scoliosis, Tanner staging and exam of genitaliaexam of genitalia

ScreeningScreening– Hemoglobin for menstruating femalesHemoglobin for menstruating females

– Urine dipstick should be done between 11 and 21Urine dipstick should be done between 11 and 21

– Cholesterol and PPD for high risk kidsCholesterol and PPD for high risk kids

Injury PreventionInjury Prevention– Seat beltsSeat belts

– No power tools unless supervisedNo power tools unless supervised

– Water activities should be supervisedWater activities should be supervised

– Children this age should not operate personal watercraftChildren this age should not operate personal watercraft

– Sunburn protection Sunburn protection

School FailureSchool Failure

Failure in school can have lifelong consequences. The causes of Failure in school can have lifelong consequences. The causes of school failure are often multiple including: chronic illness, school failure are often multiple including: chronic illness, behavioral, emotional and social issuesbehavioral, emotional and social issues

BackgroundBackground– 10 – 15% of school age children repeat or fail a grade10 – 15% of school age children repeat or fail a grade

– More likely among males, minorities, low socio-economic status and More likely among males, minorities, low socio-economic status and single parent householdssingle parent households

– Children with disabilities are nearly 3 times as likely to repeat a grade as Children with disabilities are nearly 3 times as likely to repeat a grade as those with no disability those with no disability

DisabilityDisability– LearningLearning– Speech or language impairmentSpeech or language impairment– Mental retardationMental retardation– Emotionally disturbedEmotionally disturbed

– Children who are small for gestational age are nearly twice as likely to Children who are small for gestational age are nearly twice as likely to experience school failureexperience school failure

School FailureSchool Failure

BackgroundBackground– Grade failure is linked strongly to subsequent dropping out of high Grade failure is linked strongly to subsequent dropping out of high

schoolschool10% of drop-outs had no failures10% of drop-outs had no failures22% of drop-outs failed one grade22% of drop-outs failed one grade39% of drop-outs failed 2 grades39% of drop-outs failed 2 grades

– Grade failure causes children to be older than their same-grade peersGrade failure causes children to be older than their same-grade peersOld for grade high school students are more likely to report smoking Old for grade high school students are more likely to report smoking regularly, chewing tobacco, alcohol use, driving in a car with someone who regularly, chewing tobacco, alcohol use, driving in a car with someone who has been drinking, using alcohol prior to a sexual experience and using has been drinking, using alcohol prior to a sexual experience and using cocaine or other illicit drugs.cocaine or other illicit drugs.They have more suicidal ideations, risky sexual behavior and violent They have more suicidal ideations, risky sexual behavior and violent behaviorsbehaviorsGrade retention alters peer group formationGrade retention alters peer group formationGrade retention has a negative impact on self-esteem, social adjustment, Grade retention has a negative impact on self-esteem, social adjustment, behavior, self-confidence, attitudes towards school and is stressful for behavior, self-confidence, attitudes towards school and is stressful for childrenchildren

School FailureSchool FailureConditions and Associated FactorsConditions and Associated Factors

Endogenous FactorsEndogenous Factors– Chronic diseaseChronic disease

AnemiaAnemia

AsthmaAsthma

Sleep ApneaSleep Apnea

Cystic FibrosisCystic Fibrosis

SLESLE

Crohn’s DiseaseCrohn’s Disease– Acute conditions causing school absenceAcute conditions causing school absence– Sensory impairmentSensory impairment

VisionVision

HearingHearing– Perinatal conditionsPerinatal conditions

PrematurityPrematurity

FASFAS

In utero drug exposureIn utero drug exposure

Maternal conditions affecting pregnancyMaternal conditions affecting pregnancy– Neurologic disordersNeurologic disorders

Brain injuryBrain injury

Tic disordersTic disorders

Seizure disordersSeizure disorders

Toxic exposuresToxic exposures

Endogenous FactorsEndogenous Factors– Learning disabilityLearning disability

Language and Speech DisorderLanguage and Speech Disorder– Phonologic languagePhonologic language– Expressive languageExpressive language– Receptive languageReceptive language– StutteringStuttering

Learning disorderLearning disorder– ReadingReading– WritingWriting– MathematicsMathematics

Mental RetardationMental Retardation

Communication disordersCommunication disorders

ADHDADHD

Autistic spectrum disordersAutistic spectrum disorders– Genetic disorders: Fragile xGenetic disorders: Fragile x– Endocrine disorders: HypothyroidismEndocrine disorders: Hypothyroidism– Psychiatric disordersPsychiatric disorders

Oppositional defiant disorderOppositional defiant disorder

Conduct disorderConduct disorder

OCDOCD

Anxiety disorders: phobias, panicAnxiety disorders: phobias, panic– Substance abuseSubstance abuse

School FailureSchool FailureConditions and Associated FactorsConditions and Associated Factors

Exogenous FactorsExogenous Factors

– FamilyFamilyDivorce/Separation/conflictDivorce/Separation/conflictPovertyPovertyFrequent movesFrequent movesSubstance abuseSubstance abuseDepressionDepressionAttitudes towards educationAttitudes towards education

– Low level of family supportLow level of family support– Inadequate Inadequate

accommodations for studies accommodations for studies at homeat home

– Neglect/AbuseNeglect/Abuse– EnvironmentEnvironment

Neighborhood/housingNeighborhood/housingTV/computersTV/computers

– PeersPeersPeer pressure for low Peer pressure for low performanceperformanceSubstance abuseSubstance abuse

Exogenous FactorsExogenous Factors

– Competing priorities: excessive Competing priorities: excessive extramural activitiesextramural activities

– SocialSocial– WorkWork– SportsSports– SchoolSchool

Mismatch between student and Mismatch between student and teacherteacherUnrealistic expectationsUnrealistic expectationsInadequate school environmentInadequate school environment

– Violence/safetyViolence/safety– Classroom sizeClassroom size

– TransitionsTransitionsThird gradeThird gradeElementary school to middle Elementary school to middle schoolschool

– Increases in testing standards without Increases in testing standards without increasing educational supportincreasing educational support

– Excessive testingExcessive testing

School FailureSchool FailureMedical Assessment and Subsequent InterventionsMedical Assessment and Subsequent Interventions

HistoryHistory– School historySchool history

Details of current difficultiesDetails of current difficultiesSchool settingSchool settingEducational supportEducational supportSchool absencesSchool absencesAchievementAchievementOnset of problemsOnset of problemsResults of educational testingResults of educational testingPreschool performancePreschool performanceCommunication with the schoolCommunication with the school

– Attention profileAttention profileAttentionAttentionHyperactivityHyperactivityImpulsivityImpulsivity

– Family historyFamily historyEducational achievement and Educational achievement and difficultiesdifficultiesMental retardationMental retardationADHDADHDGeneral conditionsGeneral conditions

– Tic disordersTic disorders– PKUPKU– Thyroid diseaseThyroid disease

Psychiatric disordersPsychiatric disorders– Pregnancy complicationsPregnancy complications– Birth complicationsBirth complications

PrematurityPrematurityHypoxiaHypoxiaLow Birth weightLow Birth weight

HistoryHistory– Developmental historyDevelopmental history

Motor milestonesMotor milestonesLanguage milestonesLanguage milestonesRegressionRegressionSocial skillsSocial skillsTemperamentTemperament

– Current Medical ConditionsCurrent Medical ConditionsAcuteAcuteChronicChronicMedicationsMedications

– Past medical historyPast medical historyHead traumaHead traumaCNS conditionsCNS conditions

– Sleep historySleep history– Social historySocial history

Peer groupPeer groupFamily stress: poverty, conflict, single Family stress: poverty, conflict, single parentparentFamily orientation toward educationFamily orientation toward educationMobilityMobilityExtracurricular activitiesExtracurricular activitiesSubstance abuseSubstance abuseSexual behaviorSexual behavior

– Nutrition: dietNutrition: diet– StrengthsStrengths

Developmental AssessmentDevelopmental AssessmentVision and Hearing ScreenVision and Hearing ScreenPhysical ExamPhysical ExamLaboratory screeningLaboratory screening


School Failure InterventionsSchool Failure Interventions– As indicated by assessment As indicated by assessment

(e.g., treatment of (e.g., treatment of hypothyroidism)hypothyroidism)

– Advocate for more complete Advocate for more complete assessment assessment

– Attend school meetingsAttend school meetings– Advocate for IEP that consists Advocate for IEP that consists

of more than simply having a of more than simply having a child repeat the grade that child repeat the grade that was failedwas failed

– Advocate for alternatives to Advocate for alternatives to grade retentiongrade retention

Mixed-age classesMixed-age classesIndividualized instructionIndividualized instructionTutoringTutoringHome assistance programHome assistance programSmaller class sizeSmaller class sizeAlternative education settingsAlternative education settingsGuidance counselingGuidance counseling

– Help families get more Help families get more involved in their child’s involved in their child’s educationeducation

– Assist families with peer group Assist families with peer group issuesissues

– Improve environment for Improve environment for learning at homelearning at home

Limit amount of television Limit amount of television watchingwatchingProvide a quiet place to do Provide a quiet place to do homeworkhomework

– Help develop child’s strengthsHelp develop child’s strengths– Assess siblings for school Assess siblings for school

problems and take the problems and take the opportunity to promote school opportunity to promote school readiness prior to the failure of readiness prior to the failure of a younger siblinga younger sibling


PreventionPrevention

– Promote school readiness during health supervision visitsPromote school readiness during health supervision visits

– Assess children’s strengths and weaknessesAssess children’s strengths and weaknesses

– Assess educational progress at all health supervision visitsAssess educational progress at all health supervision visits

– Implement some interventions listed previously before failure occursImplement some interventions listed previously before failure occurs

– Assess peers, activities, and health-impairing behaviorsAssess peers, activities, and health-impairing behaviors

Documents

HEALTH SUPERVISION VISIT GUIDELINES SCHOOL-AGED CHILD SUZANNE LEFEVRE MD