NEUROLOGICAL ASSESSMENT & NEURODIAGNOSTICS
Even in an era of increasingly sophisticated neurodiagnostic testing, the assessment of the child with a possible neurologic disorder begins with history, general physical exam as well as detailed neurologic examination. The standard pediatric history and physical examination are presented in Chapter 9. A careful history will allow the clinician to establish the nature and course of the illness. The progression of the illness, that is, acute, chronic, progressive or static, episodic or continuous, will help to determine the approach to the evaluation. When the developmental history is vague, other resources such as extended family members and baby books may provide clarification of prior development. Episodic events such as headaches or seizures warrant emphasis on precise details preceding and during these events. Often spells can be videotaped and this can provide important details that will assist in diagnosis.
2. Neurologic Examination
A general physical examination is an essential aspect of the assessment. Growth parameters and head circumference should be charted (see Chapter 3). A developmental assessment using an appropriate screening tool is part of every neurologic evaluation of the infant and young child and can be used to document a child's developmental status. Chapter 3 delineates age-appropriate developmental landmarks (see Tables 3–1 and 3–2). Multiple instruments are available for screening infants and children. Among these The Ages & Stages Questionnaires¯, Third Edition (ASQ-3), a parent-completed screening tool, is widely used when assessing infants and young children. The Modified Checklist for Autism in Toddlers (M-CHAT™) is a screening tool for assessing toddlers between 16 and 30 months of age for risk of autism spectrum disorders. The specifics of the neurologic examination are determined by the age of the child and the ability to cooperate in the examination. Expected newborn-infant reflexes and automations and other examination suggestions pertinent to that age group are included in Chapter 2. The hallmark of neurologic diagnosis is localization, defining where in the nervous system the "lesion" is. While not all childhood neurologic disorders are easily localized, the part of the nervous system involved, for example, central versus neuromuscular, can often be defined and will act as a guide for evaluation and diagnosis.
Table 25–1 outlines components of the neurologic examination. Much of the examination of the frightened infant or toddler is by necessity observational. An organized approach to the examination is thus imperative. Playing games will engage a toddler or preschooler: throwing and catching a ball, stacking blocks, hopping, jogging, counting, and drawing (circles, lines) can reduce anxiety and allow assessment of fine and gross motor coordination, balance, and handedness. In the older child, "casual" conversation can reveal both language and cognitive competence as will drawing, writing, calculating, and spelling.
Table 25–1.Neurologic examination: toddler age and up.