Medical/Professional Relations

Consultative Examinations: A Guide for Health Professionals

Part V - Pediatric Consultative Examination Report Content Guidelines

General Guidelines

The format for reporting the results of the history, physical examination, laboratory findings, and discussion of conclusions should follow the standard reporting principles for a complete internal medicine examination.

The report must be complete enough to help the DDS adjudicative team determine the nature, severity, and duration of the impairment and the functional limitations related to the impairment.

Content

1. Source of History
   
   The provider should indicate from whom the history was obtained and should provide an estimate of the reliability of the history.
   
   
2. History of Present Illness
   

   1. The chief complaint(s) alleged as the reason for the impairment should be discussed in detail, including:

   a. A complete description of the problem(s);
   
   b. How long the problem(s) has (have) been present;
   

   c. If episodic, provide dates of episodes, precipitating factors, and the state of health and function of the child between episodes;
   
   d. Factors that increase the problem or impairment(s);
   
   e. Factors that may provide relief;
   
   f. Any prescribed treatment and response to treatment, including compliance with treatment or lack thereof (report any side effects); and
   
   g. A description of how the impairment(s) limits the child's ability to function.

   2. Pertinent descriptive statements by the child or by the child's parent(s), other relative(s), caregiver, or other person who brought the child to the CE, such as a description of symptoms, should be recorded in the informant's own words.

   3. The pertinent negative findings that would be considered in making a differential diagnosis of the current illness or in evaluating the severity of the impairment should be included.

   4. The information must be in a narrative, rather than a "questionnaire" or "check-off" form.

3. Past History -- Description of the past history should include:
   
   
   1. The prenatal course, delivery course, and neonatal care.
      
      
   2. Prior illnesses, injuries, operations, hospitalizations, and emergency room visits, including the dates of these events. When possible for hospitalizations, diagnosis (or reason), name of facility, dates of admission/discharge, and treatment given.
      
      
4. Current Medication
   
   Current medication should be listed by name of drug and dose.
   
   
5. Review of Systems
   
   Should describe and discuss other complaints and symptoms the claimant has experienced relative to the specific organ systems, with particular emphasis on those systems that may be affected by the claimant's allegation.
   
   
6. Growth and Development History
   
   
   1. History of prior growth, when the alleged impairment would be expected to affect growth.
      
      
   2. Developmental milestones, including speech and language (if the child is under age 5).
      
      
   3. Preschool performance, if appropriate.
      
      
   4. Activities in day-care, if appropriate.
      
      
   5. School performance, including physical activity and gym (if the child is age 5 or older).
      
      
   6. Usual daily activities, including self-care, communicative abilities, social behavior with siblings, peers, and adults, details of any problems and/or need for special assistance, ability to concentrate and persist in activities as well as maintain an adequate pace.
      
      
7. Social History
   
   The social history includes pertinent findings about the child's use of tobacco products, alcohol, nonprescription drugs, etc., should be presented, if appropriate, based on the child's age.
   
   
8. Family History
   
   Information on the family history should be presented.
   
   
9. Physical Examination
   
   The report should present aspects of the physical examination dealing with the claimant's major and minor complaints in particular detail, describing both pertinent negative and positive findings. The report should include:
   
   
   1. The actual values and percentiles based on the National Center for Health Statistics data and standards for the child's:
      
      
      1. Height without shoes (length without shoes if the child is under age 2);
         
         
      2. Weight without shoes;
         
         
      3. Head circumference if the child is under age 3, or if a neurological or mental impairment is involved; and
         
         
      4. Tanner stage, as appropriate.
         
         
   2. Blood pressure, pulse, respirations, if appropriate, based on the nature of the impairment(s).
      
      
   3. General appearance of the child during exam:
      
      
      1. Any obvious vision or hearing problems;
         
         
      2. Facial dysmorphism;
         
         
      3. Skeletal anomalies;
         
         
      4. Other congenital anomalies; and
         
         
      5. Any physical evidence indicating side effects of medication.
         
         
   4. Description of child during the examination should be in a narrative, rather than a "questionnaire" or "check-off" form and should include:
      
      
      1. Behavior and attention span;
         
         
      2. How the child relates to and interacts with the examiner and the person who brought the child to the CE;
         
         
      3. Affect (is it appropriate?);
         
         
      4. Hearing;
         
         
      5. Speech (for a child up to 3 years of age, are the quantity and quality of sounds produced, both spontaneously and on imitation, age-appropriate; for a child 3 years of age and older, can the child be understood?);
         
         
      6. Receptive language (is the child's understanding of what is said to him/her age-appropriate in terms of vocabulary, content, etc., e.g., one-step directions, then two- and three-step directions?);
         
         
      7. Expressive language (is the child's production of language age-appropriate, e.g., use of single words, then phrases, and then sentences?);
         
         
      8. Communicative ability (can the child -- of any age -- express different communicative intents (e.g., requests objects by age-appropriate nonverbal or verbal means), and engage in age-appropriate communicative behaviors (e.g., turn-taking, establishing and maintaining a topic)?); and
         
         
      i. Physical activity -- gait, manipulation skills, sitting, crawling, walking, ability to roll over (for infants).
      
      NOTE: Pelvic examinations should not be performed unless specifically authorized.
      
      J. Laboratory Tests
      
      
   1. The results of the laboratory test reports should provide:
      
      
      1. Actual values for laboratory tests; and,
         
         
      2. Normal ranges of values for the child's age in either the medical report or the laboratory report.
         
         
   2. Reports of x-rays and other imaging studies of those body areas specifically requested should be provided.
      
      
   3. Interpretation
      
      
      1. The interpretation of laboratory tests (e.g., electrocardiographic tracings) or imaging studies must take into account and be correlated with the history and physical examination findings.
         
         
      2. Identify the physician (psychologist) providing the formal interpretation, when it is other than the physician (psychologist) signing the CE report.
         
         
      3. If the interpretation is provided separately, the report sheet should state the interpreting physician's (psychologist's) name and address.
         
         

   K. Other Testing
   
   Developmental screening (e.g., the Denver Developmental Screening Test) should be performed, if appropriate.

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Report Content by Specific Impairment

Listed in the following sections are specific requirements to be addressed for individual allegations in addition to the general guidelines above.

An impairment may significantly affect other body systems; in such cases, the additional body system must be evaluated as well.

Pediatric - Growth

In addition to the general guidelines:

1. History -- The history should include:
   
   
   1. Any growth delay causally related to any medically determinable impairment;
      
      
   2. Any delays in the growth and/or development of siblings (include ages of siblings); and,
      
      
   3. Heights of parents and siblings (Is the child's growth pattern related to a constitutional growth delay or familial short stature?).
      
      
2. Laboratory Testing - Laboratory testing should include bone-age determination, when appropriate.
   

Go to Listing of Impairments- Childhood: Growth Impairment 100.00 for more information.

Pediatric - Musculoskeletal

In addition to the general guidelines:

Physical Exam -- The physical exam should include:

1. Description of any deformity;
   
   
2. Any functional limitations based on descriptions of limb or truncal abnormalities as related to age (note any obvious or subtle limitations); and
   
   
3. Any need for an assistive device.
   

Go to Listing of Impairments - Childhood: Musculoskeletal System 101.00 for more information.

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Pediatric - Special Senses and Speech

In addition to the general guidelines:

1. Visual Impairments
   
   
   1. The history should include the child's visual behavior (for children under 3 years of age).
      
      
   2. The report should note whether any eye abnormality exists.
      
      
   3. Testing should include visual acuity and visual field measurements, when possible.
      
      
2. Hearing Impairments
   
   For children 5 years of age or older, audiometry should include measurement of speech discrimination.
   
   
3. Speech and Language Disorders
   
   
   1. Children - Birth to Attainment of Age 3
      
      
      1. Developmental History:
         
         
         1. Record alleged speech-language problem, with specific examples.
            
            
         2. Review developmental milestones for speech-language, including cooing, babbling, jargoning, first words, phrases, sentences. Note age at which milestones achieved; correct chronological age for prematurely up to age 24 months, if applicable.
            
            
         3. Note early feeding and eating behavior (e.g., swallowing, ability to tolerate various food textures and temperatures).
            
            
         4. Identify significant birth and post-natal history; history of ear infections or hearing loss; use of PE tubes or hearing aid (s); family history of communication problems; developmental problems in other areas.
            
            
         5. Report participation in previous/current speech-language therapy and progress made.
            
            
         6. Indicate primary language used in home if family is bilingual or non-English speaking.
            
            
      2. Comprehensive Speech Testing
         
         
         1. Conduct an Oral-Peripheral examination.
            
            
            1. Examine and describe structural aspect of the oral mechanism.
               
               
            2. Note unusual oral-motor behaviors such as presence of excessive drooling, excessive mouthing of objects, aversion to oral-related activities such as brushing teeth.
               
               
            3. Observe interest in, and ability regarding, imitation of nonspeech-motor and speech-motor movements.
               
               
            4. Determine integrity of sensorimotor mechanism as related to development of speech.
               
               
         2. List sounds in child's repertoire, and note frequency of use.
            
            
         3. Describe child's play with sounds (e.g., ability to vary pitch, change intensity, produce "raspberries," squeals, and tongue clicks).
            
            
         4. Evaluate stage of child's sound-making (e.g., cooing, one-syllable babbling, reduplicative babbling, non-reduplicative babbling, jargoning, mature jargoning).
            
            
         5. Comment on frequency and ease with which child is able to use and vary sound patterns and combinations.
            
            
         6. Determine whether or not child's sound patterns are typical, delayed, or atypical for the child's age.
            
            
         7. Comment on whether speech is sufficient to support the development of expressive language.
            
            
         8. Comment on overall intelligibility of speech (if child is using words) and whether the degree of intelligibility is within expectancy for child's age.
            
            
         9. Observe voice quality and its impact on intelligibility.
            
            
         10. Indicate whether speech fluency is developmentally appropriate.
             
             
         11. Comment on adequacy of breath support for speech as it relates to intensity, the capacity to sustain speech, and the ability to maintain a normal rate of vocal/verbal turn taking.
             
             
      3. Comprehensive Language Testing:
         
         
         1. Include a current, well-standardized comprehensive communication battery when possible (e.g., The MacArthur Communicative Development Inventory: Words and Gestures; Preschool Language Scale-III (PLS-3)), appropriate to child's age (and native language, when available).
            
            
            1. State full title of test and include test/subtest means and standard deviations (if reported for the test).
               
               
            2. Report total language standard score (SS); area composite SSs when part of test protocol (e.g., PLS-3 Auditory Comprehension); and age equivalents (if needed).
               
               
            3. Comment on the validity of test results with regard to the child's behavior (e.g., cooperation, interest, attention/concentration).
               
               
            4. Send completed test protocols along with report of evaluation.
               
               
         2. Supplement formal test results with parent questionnaire (e.g., REEL, Rosetti Infant-Toddler Language Scales) when appropriate. Determine language age equivalencies, as appropriate.
            
            
         3. Provide clinical observations and descriptions, as well as parent/caregiver report, of child's spontaneous language understanding and production, and compare to:
            
            
            1. language skills of typically developing, same-age peers, and
               
               
            2. child's cognitive level (if known).
               
               
         4. Provide information about the child's:
            
            
            1. Primary mode of communication, verbal or nonverbal;
               
               
            2. Use of gestures (e.g., communicative pointing, showing objects);
               
               
            3. Ability to engage in reciprocal eye gaze and joint referencing;
               
               
            4. Ability to engage in turn-taking, first at the sound level, and later, at the spoken language level;
               
               
            5. Total number of words in vocabulary (regardless of clarity), and whether range of semantic relations is expressed;
               
               
            6. Occurrence, frequency, and quality (e.g., novel and rule-governed, stereotypic) of multiword utterances;
               
               
            7. Mean length of typical utterances;
               
               
            8. Range of communicative intentions expressed (such as labeling, requesting, socializing).
               
               
      4. Conclusions:
         
         1. The Speech-Language Pathologist (SLP) signing the report must review the reported findings, which must represent the information obtained in the examination of the child.
            
            
         2. The conclusions provided by this SLP must correlate with the findings from the history, observations, and formal testing obtained in conjunction with this examination.
            
            
         3. All abnormalities should be explained, or commented upon if an explanation cannot be provided.
            
            
         4. Discuss whether, based on test results and clinical observations, the speech and/or language disorder would be likely to affect child's learning and/or social development.
            
            
         5. The SLP must sign the report and identify educational degree and certification and/or licensure credentials.
            
            
   2. Children, Age 3 Years and Older
      
      1. Developmental History:
         
         
         1. Record alleged speech-language problem, with specific examples.
            
            
         2. Identify significant birth and post-natal history; history of feeding problems; history of ear infections or hearing loss; use of PE tubes or hearing aid(s); family history of communication problems.
            
            
         3. Report participation in previous/current speech-language therapy and progress made.
            
            
         4. Indicate child's primary language and primary language used in home if family is bilingual or non-English-speaking.
            
            
      2. Comprehensive Speech Testing:
         
         1. Conduct an Oral-Peripheral examination.
            
            1. Examine and describe structural aspect of the oral mechanism.
               
               
            2. Determine performance on imitative tasks involving both nonspeech-motor and speech-motor movements, including both sequenced and unsequenced patterns.
               
               
         2. Provide clinical observations and descriptions, as well as parent/caregiver report, of articulation, voice, and fluency, and compare to:
            
            1. Speech skills of typically developing, same-age peers, and
               
               
            2. Child's cognitive level (if known).
               
               
         3. Provide information about:
            
            1. Overall speech intelligibility (in percentages) at conversational level based on a speech sample; comment on intelligibility with both familiar and unfamiliar listeners and when topic is known and unknown, if relevant to child's age and experiences;
               
               
            2. Ability to improve intelligibility, and by what percentage, upon repetition or imitation of message;
               
               
            3. Patterns of articulation errors and/or phonological processes, with statements as to whether patterns of errors/processes are developmental, delayed, or atypical for (cognitive) age; provide at least 2 examples;
               
               
            4. Pattern of dysfluencies and presence/absence of secondary or struggle/tension behavior with statements as to whether dysfluencies are developmental or atypical for (cognitive) age;
               
               
            5. Voice quality and its impact on intelligibility;
               
               
            6. Adequacy of breath support as it relates to intensity, the capacity to sustain speech, and the ability to maintain a normal rate of conversation.
               
               
            7. Contributing effect of any motor-based speech disorders (e.g., dyspraxia, dysarthria);
               
               
            8. Use of dialectal variations in speech patterns.
               
               
         4. Include a current assessment tool (e.g., Weiss Comprehensive Articulation Test, Riley Stuttering Prediction Instrument for Young Children) if needed to validate ratings of intelligibility at the conversational level.
            
            
            1. State full name of test.
               
               
            2. Include scores and operational definitions of terms, as appropriate.
               
               
            3. Discuss validity of test results with regard to child's cooperation, interest, and attention/concentration.
               
               
            4. Send completed test protocols along with report of evaluation.
               
               
      3. Comprehensive Language Testing:
         
         
         1. Use a current, well-standardized comprehensive language battery that measures semantic and syntactic competency in both receptive and expressive modes, and that is appropriate to the child's chronological age (and native language, when available).
            
            
            1. Include full title of test (s) used, as well as test/subtest means and standard deviations (SD).
               
               
            2. Report the child's total language standard score (SS); area composite SSs (e.g., PLS-3 Auditory Comprehension, TOLD-3:I Semantic Composite); and individual subtest SSs (e.g., CELF-3 Oral Directions) when these are part of the test protocol. If the test does not calculate discrepancies from the norm to 3 SD or more below the mean, and the child's score falls below the lowest SS provided, indicate this fact in report.
               
               
            3. Discuss validity of test results with regard to child's behavior (e.g., cooperation, interest, and attention/concentration).
               
               
            4. Send completed test protocols along with report of evaluation.
               
               
         2. Provide clinical observations and descriptions, as well as parent/caregiver report, of spontaneous language understanding and production, and compare to:
            
            
            • Language skills of typically developing same-age peers, and
              
              
            • Child's cognitive level (if known).
              
              
            1. Based on a spontaneous language sample, comment on child's overall receptive language skills (e.g., ability to follow directions) and overall expressive language skills (e.g., Mean Length of Utterance (MLU) for younger children, syntactic usage for older children) when child is engaged in spontaneous conversation.
               
               
            2. Based on a spontaneous language sample, discuss development of conversational skill as it relates to child's chronological age. For example, does the child:
               
               
               • Produce a full range of communicative intentions, e.g., requesting, responding, directing, commenting, labeling, stating, describing, informing?
                 
                 
               • Engage in verbal/nonverbal turn-taking?
                 
                 
               • Establish and maintain conversational topics?
                 
                 
               • Identify and repair miscommunications?
                 
                 
               • Take into account listener's background and knowledge (i.e., child's ability to use pre-suppositional knowledge)?
                 
                 
            3. Discuss development of narrative skill as it relates to child's chronological age. For example, does child
               
               
               • 3 years and older retell experiences and events (that are not immediate occurrences) in an increasingly appropriate sequence?
                 
                 
               • 6 years and older produce narratives that have intact basic story structure (e.g., setting, beginning, middle, end, resolution of conflict)?
                 
                 
               • 12 years and older generate coherent stories using linguistic tools (e.g., use pronouns, conjunctions) in order to tie elements of one sentence to those of another?
                 
                 
      4. Conclusions:
         
         
         1. The SLP signing the report must review the reported findings, which must represent the information obtained in the examination of the child.
            
            
         2. The conclusions provided by this SLP must correlate with the findings from the history, observations, and formal testing obtained in conjunction with this examination.
            
            
         3. All abnormalities should be explained, or commented upon if an explanation cannot be provided.
            
            
         4. Discuss whether, based on test results and clinical observations, the speech and/or language disorder would be likely to affect child's learning and/or social development.
            
            
         5. Comment on whether child's language test profile reflects his/her everyday language skills (i.e., oral language skills, language-learning skills) or school language skills (i.e., literacy skills, metalinguistic skills) or a combination of these.
            
            
         6. The SLP must sign the report and identify educational degree and certification and/or licensure credentials.
            

Go to Listing of Impairments - Childhood: Special Senses and Speech 102.00 for more information.

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Pediatric - Respiratory

In addition to the general guidelines:

1. History -- The history should include a description of:
   
   
   1. Dyspnea, wheezes, cough, etc.;
      
      
   2. Frequency, severity, and duration of symptoms and other episodes of respiratory problems; and
      
      
   3. Response to medication.
      
      
2. Physical Exam -- The physical exam report should include:
   
   
   1. A description of any visible chest wall abnormality;
      
      
   2. Cyanosis and clubbing; and
      
      
   3. Auscultation findings.
      
      
3. Laboratory Testing -- Laboratory testing should include, as appropriate:
   
   
   1. Pulmonary function testing;
      
      
   2. Arterial blood gas studies;
      
      
   3. Pulse oximetry; and
      
      
   4. Chest X-ray.
      

Go to Listing of Impairments - Childhood: Respiratory System 103.00 for more information.


Pediatric - Cardiovascular

In addition to the general guidelines:

1. History -- The history should include, as appropriate, the description of:
   
   
   1. Characteristic squatting;
      
      
   2. Hemoptysis;
      
      
   3. Syncope;
      
      
   4. Hypercyanotic spells;
      
      
   5. Exercise tolerance;
      
      
   6. Poor weight gain;
      
      
   7. Poor growth; and
      
      
   8. Feeding problems (in infants).
      
      
2. Physical Exam -- The physical exam should include:
   
   
   1. Blood pressure (upper and lower extremities, standing and sitting);
      
      
   2. Heart sounds, murmurs;
      
      
   3. Peripheral pulses;
      
      
   4. Cyanosis (perioral, peripheral);
      
      
   5. Pallor;
      
      
   6. Respiratory distress;
      
      
   7. Tachypnea;
      
      
   8. Clubbing;
      
      
   9. Tachycardia;
      
      
   10. Arrhythmia;
       
       
   11. Hepatomegaly;
       
       
   12. Edema; and,
       
       
   13. Perspiring with crying (in infants).
       
       
3. Laboratory Testing -- Laboratory testing should include, as appropriate:
   
   
   1. EKGs;
      
      
   2. Chest x-rays; and
      
      
   3. Pulse oximetry.
      

Go to Listing of Impairments - Childhood: Cardiovascular System 104.00 for more information.

Pediatric - Digestive

In addition to the general guidelines:

1. History -- The history should include a description of:
   
   
   1. Any feeding problems during infancy;
      
      
   2. The child's usual diet; and
      
      
   3. Stool patterns.
      
      
2. Physical Exam -- The physical exam should include:
   
   
   1. Liver and spleen size;
      
      
   2. Presence of any jaundice;
      
      
   3. Comments on nutritional status;
      
      
   4. Rectal exam;
      
      
   5. Presence of any abdominal distention; and
      
      
   6. For infants and toddlers, observation of the child eating or drinking, if possible, and comment on observations.
      
      
3. Laboratory Testing -- Laboratory testing should include, if appropriate:
   
   
   1. Stool Fat;
      
      
   2. Serum carotene;
      
      
   3. Liver function tests; and
      
      
   4. Total serum protein and albumin.
      

Go to Listing of Impairments - Childhood: Digestive System 105.00 for more information.

Pediatric - Genito-Urinary

In addition to the general guidelines:

1. History -- The history should include:
   
   
   1. Urinary frequency;
      
      
   2. Dysuria;
      
      
   3. Hematuria;
      
      
   4. Any enuresis or incontinence; and
      
      
   5. Any previous urinary tract infection.
      
      
2. Physical Exam -- The physical exam should include a description of any:
   
   1. Masses;
      
      
   2. Abnormality of genitalia; and
      
      
   3. Edema or anasarca.
      
      
3. Laboratory Testing -- Laboratory testing should include, as appropriate:
   
   1. Creatinine; and
      
      
   2. Total serum protein and albumin.

Go to Listing of Impairments - Childhood: Genito-Urinary System 106.00 for more information.


Pediatric - Hemic and Lymphatic

In addition to the general guidelines:

1. History -- The history should include:
   
   
   1. Fatigue/anorexia;
      
      
   2. Headache;
      
      
   3. Pain;
      
      
   4. Weight loss/gain;
      
      
   5. Edema;
      
      
   6. Jaundice;
      
      
   7. Bleeding - ecchymoses;
      
      
   8. Transfusions (RBCs, platelets, plasma factors) - frequency; and,
      
      
   9. Infections.
      
      
2. Physical Exam -- The physical exam should include:
   
   
   1. Jaundice;
      
      
   2. Abnormal bleeding;
      
      
   3. Liver and spleen size;
      
      
   4. Size and distribution of lymph nodes; and
      
      
   5. Abdominal masses.
      
      
3. Laboratory Testing -- Laboratory testing should include:
   
   
   1. CBC, including reticulocyte count;
      
      
   2. Serial hematocrits (at least three) over a 12-month period, if available; and,
      
      
   3. Chest X-ray.
      

Go to Listing of Impairments - Childhood: Hemic and Lymphatic System 107.00 for more information.

Pediatric - Skin

In addition to the general guidelines:

The history should include any effects on age-appropriate activity, especially social behavior, because of disfigurement.

Pediatric -- Endocrine

In addition to the general guidelines:

1. Thyroid Disorders
   
   
   1. History -- The history should describe:
      
      
      1. Episodes of constipation/diarrhea;
         
         
      2. Appetite;
         
         
      3. Energy level;
         
         
      4. School performance;
         
         
      5. Sleep patterns;
         
         
      6. Sweating;
         
         
      7. Growth;
         
         
      8. Weight gain/loss; and
         
         
      9. Personality dysfunction.
         
         
   2. Physical Exam -- The physical exam should include a description of any goiter present.
      
      
   3. Laboratory Testing - Laboratory testing should include developmental screening, if appropriate.
      
      NOTE: A more comprehensive psychological CE may be needed to address allegations of developmental delay due to hypothyroidism.
      
      
2. Hypoparathyroidism
   
   
   1. History -- The history should include the information in A.1. above.
      
      
   2. Physical Exam -- The physical exam should describe:
      
      
      1. The presence of Trousseau or Chvostek signs, and
         
         
      2. Any evidence of tremulousness.
         
         
   3. Laboratory Testing
      
      See A.3. above for the testing.
      
      
3. Hyperparathyroidism
   
   
   1. History -- In addition to the information in A.1. above, the history should include:
      
      
      1. Episodes of constipation;
         
         
      2. Abdominal pain; and
         
         
      3. Bone pain.
         
         
   2. Physical Exam
      See B.2. above for the information to be included in the physical exam.
      
      
   3. Laboratory Testing
      See A.3. above for the testing.
      
      
4. Diabetes Mellitus
   
   
   1. History -- The history should include:
      
      
      1. Any polyuria or polydypsia;
         
         
      2. Weight loss and change of appetite;
         
         
      3. Frequency and duration of hospitalizations;
         
         
      4. Frequency and severity of hypoglycemic episodes; and
         
         
      5. As appropriate, any evidence of complications with reference to the appropriate involved body system.
         
         
   2. Treatment -- The description of treatment should include:
      
      
      1. Insulin dosage;
         
         
      2. Compliance with medication; and
         
         
      3. Compliance with diet (e.g., number of calories, structure of diet).
         
         
5. Adrenogenital
   
   
   1. History -- The history should include:
      
      
      1. Episodes of salt-losing crises (including frequency);
         
         
      2. Social/behavior problems (give details); and,
         
         
      3. A description of any treatment and response to treatment, including any surgical procedures.
         
         
   2. Physical Exam
      
      The physical exam should describe the presence of any growth problems. (See discussion under "Pediatric -- Growth.")
      

Go to Listing of Impairments - Childhood: Endocrine System 109.00 for more information.

Pediatric -- Multiple Body Systems

In addition to the general guidelines:

Down Syndrome

The history should include evidence that it is of the non-mosaic form. Testing must demonstrate non-mosaic form. A statement of Down Syndrome is not sufficient.

Go to Listing of Impairments - Childhood: Multiple Body Systems 110.00 for more information.

Pediatric - Neurological

In addition to the general guidelines:

1. Description For Seizures
   
   If seizures are present, there should be a description of:
   
   
   1. Type;
      
      
   2. Abnormal behavior prior to seizure;
      
      
   3. Aura;
      
      
   4. Frequency, time of occurrence, provocative factors;
      
      
   5. Nature and duration of seizure activity;
      
      
   6. Post-ictal state;
      
      
   7. Duration of Post-ictal state;
      
      
   8. Medication with dosage (including any recent adjustments to medication);
      
      
   9. Response to treatment;
      
      
   10. Side effects of medication;
       
       
   11. Any signs of injury due to seizures;
       
       
   12. Episodes of headache;
       
       
   13. Pain;
       
       
   14. Incontinence;
       
       
   15. Speech and language abnormalities;
       
       
   16. Weakness; and
       
       
   17. Abnormal movements and coordination.
       
       
2. Physical Exam -- The physical exam should include a description of the claimant's:
   
   
   1. Mental status (e.g., orientation);
      
      
   2. Reflexes, balance, strength;
      
      
   3. Fine motor skills;
      
      
   4. Gait (where age-appropriate);
      
      
   5. Coordination and abnormal movements, at rest and with activity, if any; and
      
      
   6. Sensory examination.
      
      NOTE: When formal muscle strength testing is not possible for younger children, record observations of sitting, pulling, rolling over, rising from supine position, etc.
      
      

Go to Listing of Impairments - Childhood: Neurological System 111.00 for more information.

Pediatric - Mental Disorders

In addition to the general guidelines:

1. Infants And Toddlers -- The mental assessment for infants and toddlers should include:
   
   
   1. History, including age of attainment of developmental milestones (sitting unsupported, standing, walking);
      
      
   2. Responsiveness to visual, auditory, and tactile stimuli (birth to 12 months);
      
      
   3. Motor coordination (fine/gross, including left or right dominant);
      
      
   4. Communicative behaviors, including pre-speech behaviors (e.g., sucking, swallowing, imitation of sounds) and early language behaviors (e.g., jargon, single words, phrases, turn-taking));
      
      
   5. Manner of relating to and interacting with parent or caregiver, and ability to separate from parent/caregiver;
      
      
   6. Manner of relating to and interacting with sibling or peer group, if observed;
      
      
   7. Any stereotypical movements;
      
      
   8. Perceptual functioning; and
      
      
   9. Other pathology.
      
      
2. Children Of All Ages -- The report of mental assessment for children of all ages (or the mental status exam for children 12 and over) should include a description of:
   
   
   1. History, including adjustment in school and home (daily activities, social functioning, concentration, persistence, pace);
      
      
   2. Appearance and grooming;
      
      
   3. Behavior;
      
      
   4. Concentration;
      
      
   5. Affect;
      
      
   6. Communicative abilities and behavior;
      
      
   7. Thought processes (with verbatim examples);
      
      
   8. Cognitive functioning, including psychological test findings; and
      
      
   9. Any indication of substance abuse, self-injury.
      
      
3. Children Age 12 And Over -- In addition to B. above, the mental status exam for children age 12 and over should include:
   
   
   1. Judgment and insight;
      
      
   2. Impulse control;
      
      
   3. Orientation;
      
      
   4. Memory; and
      
      
4. Homicidal/suicidal ideation.
   
   NOTE: These elements may also be appropriate for children under age 12.
   

Go to Listing of Impairments - Childhood: Mental Disorders 112.00 for more information.

Pediatric - Neoplasm

In addition to the general guidelines:

The history should include evidence of response to treatment and/or any spontaneous remissions and duration thereof.

Go to Listing of Impairments - Childhood: Neoplastic Diseases 113.00 for more information.

Pediatric - Immune System

In addition to the general guidelines, the history should include:

• Details of treatment, response to treatment, and any side effects of treatment.
   
• Frequency and severity of any infections, particularly those requiring hospitalization, with the dates of these events.
   
• Reference to specific organ involvement, as applicable, and discussion of involved organ systems.
  

Go to Listing of Impairments - Childhood: Immune System 114.00 for more information.

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