Ask the child to "stick out your tongue all the way."

An important part of the motor examination is to observe the child's gait In children with uncoordinated while the child is walking and, optimally, running. Note any asymmetries, gait, be sure to distinguish ortho-weakness, undue tripping or clumsiness. Follow the DDST examination pedic causes such as positional

milestones to test for appropriate maneuvers such as heel-to-toe walking (photo below), hopping, and jumping. Use a toy to test for coordination and strength of the upper extremities.

Ifyou are concerned about the child's strength, have the child lie on the floor and then stand up, and closely observe the stages. Most normal children will first sit up, then flex the knees and extend the arms to the side to push off from the floor and stand up.

Hand preference is demonstrated in most children by age 2 and rarely before 18 months of age.

The sensory examination can be performed using a cotton ball or tickling the child. This is best performed with the child's eyes closed. Do not use pin pricks to evaluate sensation or else you will have a very uncooperative and unhappy patient!

Deep tendon reflexes can be tested as in adults. First demonstrate the use of the reflex hammer on the child's hand, assuring the child that it will not hurt. Children love to feel their legs bounce when you test their patellar reflexes. You will need to have the child cooperate and keep the eyes closed during some of this examination because tensing will disrupt the results.

You can ask children older than 3 years to draw a picture, copy objects as is done in the DDST, and then discuss their pictures to test simultaneously for fine motor coordination, cognition, and language.

The cerebellar examination can be tested using finger to nose and rapid alternating movements of the hands or fingers. Children enjoy this game. Children older than 5 years should be able to tell right from left, so you can assign them right-left discrimination tasks as is done in the adult patient.

deformities of the hip, knee, or foot from neurologic abnormalities such as cerebral palsy, ataxia, neuromuscular conditions producing weakness, or degenerative diseases.

In certain forms of muscular dystrophy with weakness of the pelvic girdle muscles, children will rise to standing by rolling over prone and pushing off the floor with the arms while the legs remain extended (Gower's sign).

It is important to distinguish between isolated delays in one aspect of development (e.g., coordination or language) and more generalized delays that occur in several components. The latter is more likely to reflect global neurologic disorders such as mental retardation that can be caused by a large number of etiologies.

Use the expected milestones on the DDST and on pp. 628-631 to test for language, cognitive, and social and emotional development. Remember that the neurologic and developmental examinations require a cooperative child, so be patient, have fun, and don't be embarrassed to play and innovate as you refine your examination skills to the developmental level of your pediatric patient.

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