A 9-month-old child is brought to the office for a routine visit. The patient has had several episodes of otitis media since birth, but no major illnesses or hospitalizations. She was previously happy and sociable around other people but now cries when her mother is not in the room and screams when going to day care. Developmentally, the child pulls herself up to stand and can stand on her own briefly. She can hold a spoon with 3 fingers and throw objects. The patient does not yet respond to her name, babble, or use words. When the physician hides a toy with his hand, the child lifts the hand to look for it. She waves goodbye when the physician waves first. Which of the following is the best next step in management of this patient?

Question

A 9-month-old child is brought to the office for a routine visit.  The patient has had several episodes of otitis media since birth, but no major illnesses or hospitalizations.  She was previously happy and sociable around other people but now cries when her mother is not in the room and screams when going to day care.  Developmentally, the child pulls herself up to stand and can stand on her own briefly.  She can hold a spoon with 3 fingers and throw objects.  The patient does not yet respond to her name, babble, or use words.  When the physician hides a toy with his hand, the child lifts the hand to look for it.  She waves goodbye when the physician waves first.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_d275_6b3a_bc81_01f136efbc2c_MD0003_00 Evaluation for developmental delay includes assessment of motor, cognitive, social/emotional, and verbal milestones. This child is meeting gross and fine motor milestones (stands unassisted for a short time, throws objects, holds utensils). Physical therapy is not indicated (Choice B). Cognitively, infants develop object permanence at age 6-12 months and realize when specific people or objects are not present. This is demonstrated by the girl's ability to find a toy covered by a hand as well as by her separation anxiety, which usually manifests at age 9-18 months when parents leave the room or at bedtime. The physician should reassure the mother that separation anxiety is normal at 9 months and should improve over time. The concerning feature is the child's delay in verbal milestones. At age 9 months, she should be babbling; using small, nonspecific words (eg, "mama," "dada"); and responding to her own name. Her presentation and history of recurrent otitis media raise concern for a hearing problem and the need for an audiology evaluation. (Choice C) Normal childhood separation anxiety should be distinguished from separation anxiety disorder. In the latter, children have an unreasonable fear of being separated from a loved one and can present with severe symptoms, such as panic attacks and vomiting. Children with these symptoms should undergo a psychological evaluation. (Choice D) The mother can be reassured that her child's motor and social development are normal, but her verbal development requires further evaluation. (Choice E) This child interacts with the physician, with no concerning findings on history or physical examination aside from her verbal delay. A social services consult is not required. Educational objective: Children age 9 months should be able to grasp objects, pull to stand, babble, say some words, and respond to their name. Some separation anxiety is developmentally normal at age 9-18 months. Delayed verbal milestones should be assessed with an audiological evaluation. References: Identifying infants and young children with developmental disorders in the medical home: An algorithm for developmental surveillance and screening. (http://www.ncbi.nlm.nih.gov/pubmed/16818591) Separation anxiety: At the neurobiological crossroads of adaptation and illness. (http://www.ncbi.nlm.nih.gov/pubmed/26487808)

A 9-Month-Old Child Is Brought to the Office for a Routine