How would an FNP assess the patient’s language skills in the office?
The FNP would conduct a thorough developmental history and assessment of the child’s language skills in the office. This would include using a standardized developmental screening tool to evaluate his receptive and expressive language abilities compared to typical developmental milestones (Oogarah-Pratap et al., 2020). Observing his interactions, ability to follow simple commands, and pointing to pictures in books could provide valuable insights.
What will need to be done clinically?
The FNP will first conduct a comprehensive developmental screening using a standardized tool such as the Ages and Stages Questionnaires to formally evaluate the child’s language skills compared to typical milestones for his age (Oogarah-Pratap et al., 2020). A complete hearing evaluation will also be performed to rule out any sensory impairments. Based on the screening results, the child will likely be referred to an early intervention program where a speech-language pathologist can complete a formal language and communication assessment and begin providing targeted therapy. The parents will also be educated on developmental milestones, activities to support language development at home through interactions, reading and responding to the child, and the importance of scaffolding language skills (Kanwal et al., 2023). Further clinical evaluation, including laboratory tests, may be necessary to rule out potential genetic causes, and the child would need follow-up visits in a few months to monitor his progress with screening and therapy, looking for additional referral needs if delays persist.
Discuss possible differential diagnoses and how the PCP can rule them out. What stage of child development is the child in?
Some potential differential diagnoses to consider and rule out include sensory impairment, autism spectrum disorder, genetic syndromes, or developmental delay (Oogarah-Pratap et al., 2020). Hearing loss is a concern and could cause language delays, so the PCP will conduct formal audiological testing to rule this out (Kanwal et al., 2023). Autism spectrum disorder (ASD) could present with delayed language milestones and a lack of social engagement. However, the child responds to his name and enjoys books, making ASD less likely but still a consideration. Referral to a developmental pediatrician may help rule this in or out.
Theorists compare this child’s development stage and their relationship.
Thinking remains egocentric and intuition over logic. This matches the child’s ability to point to pictures and understand words, even if their vocabulary is limited. Piaget would expect them to learn words rapidly at this stage and interpret the world based more on their perceptual perspectives than abstract reasoning. Vygotsky’s sociocultural theory emphasizes the critical role of social interaction and culture in children’s development. Vygotsky stressed that providing enriching social opportunities through shared book reading, play, and modeling appropriate language would help this child progress in their burgeoning vocabulary and expressions. Both interaction and play allow children to stretch beyond their developmental level with guidance.
The FNP would conduct a thorough assessment, including screening, history, observation, and ruling out potential causes through appropriate testing/referrals. According to Piaget, the child exhibits language delays consistent with the preoperational stage. Vygotsky’s perspective highlights the need to support his linguistic development through social interactions and play. Piaget’s stages and Vygotsky’s perspectives align with the typical developmental profile of a 2-year-old child seen here. Their theories help inform how to best facilitate this patient’s ongoing language acquisition by evaluating their current functioning and providing environmental support within their zone of proximal development.
Assessment Description
Specific Patient Education and Anticipatory Guidance
I would educate the parents that their child’s language development is consistent with typical 2-year-old milestones (primary prevention). However, to support his progression, they should talk, read, and sing with him daily using simple words and visual aids (secondary prevention). Enrolling him in early intervention speech therapy will help target his needs through play activities (tertiary prevention). The parents should monitor his ongoing response using a screening tool every three months and notify me if he needs to make adequate gains. I encourage enriching parent-child interactions, limiting screen time, and maintaining regular well-child visits to promote his language and cognitive skills as he enters the next developmental stage.
Health Promotion and Disease Prevention Guidelines
It is essential to promote wellness from an early age. Regular primary care visits allow monitoring of developmental milestones and screening for risks like family history of genetic conditions. Immunizations on schedule guard against vaccine-preventable illnesses. Nutrition counseling helps establish healthy eating habits to prevent obesity and gives guidance on introducing solids. Proper car seat and home safety aim to prevent injuries. Maintaining dental hygiene from an early age prevents cavities. Some families face barriers to care, like lack of insurance, transportation, or sick leave from work. Resources for local low-cost services can help improve access to preventive care and develop positive health attitudes.
Potential Specialist Referrals and Other Service Providers
For this patient, the PCP may refer to a pediatric speech-language pathologist and a developmental pediatrician to further assess the child’s delays. The local school district offers free early intervention services through Part C of the Individuals with Disabilities Education Act to provide speech therapy in the home or classroom setting (Francisco et al., 2020). At the state level, the Department of Health and Human Services funds programs like First Words that connect families to community resources for children with special needs (Maani & Galea, 2020). Nationally, organizations like Hands & Voices promote support through various services for families with children who are deaf or hard of hearing. Globally, groups like the Optimus Foundation work to expand access to screening and interventions for at-risk infants in low-resource areas.
SOAP Note
S: CC: Concerned about lack of speech
Pt: John Doe
Age: 2 years old
Setting: Well child visit
S: HPI: Parents report John says only 15 words and mostly babbles. Points to self and responds to name. Allows books to be read and imitates words while pointing.
S: History: Unremarkable PMH and surgical history. My younger sister is developing typically. Live with parents, no smoking/exposure.
S: ROS: Denies symptoms in all other systems.
O: Exam: Well-nourished boy in no distress. Follows commands. Points to body parts. Attempts words but limited vocabulary. Hearing within normal limits to tuning fork. Normal tone/strength.
A: Differential includes behavioral delay, hearing loss, and autism. It is likely behavioral due to age and responses to the environment.
P: Refer to the Early Intervention program for formal speech therapy evaluation and home services. Monitor with ASQ questionnaire every three months and reconnect in 6 months. Counsel parents to continue reading, naming objects, and limiting screens. Reviewed safety, nutrition, and dental hygiene. E/M: 99394
A: The plan focuses on early intervention to remediate delays through formal therapy and home activities. Comprehensive anticipatory guidance addresses health promotion, including counseling a safe home environment, establishing healthy routines, and identifying community resources. Regular follow-up will monitor progress and identify if additional evaluation/management is needed.
References
Francisco, M. P. B., Hartman, M., & Wang, Y. (2020). Inclusion and special education. Education Sciences, 10(9), 238. https://doi.org/10.3390/educsci10090238
Kanwal, W., Mehmood, K., & Perveen, R. (2023). Development of skills at the preoperational stage; A comparative study on Cognitive development of Urban and rural children. Journal of Early Childhood Care & Education, 7(1). DOI: 10.30971/jecce. v7i1.1450
Maani, N., & Galea, S. (2020). COVID‐19 and underinvestment in the public health infrastructure of the United States. The Milbank Quarterly, 98(2), 250. doi: 10.1111/1468-0009.12463
Oogarah-Pratap, B., Bholoa, A., & Ramma, Y. (2020). Stage theory of cognitive development—Jean Piaget. Science Education in Theory and Practice: An Introductory Guide to Learning Theory, 133-148. https://link.springer.com/chapter/10.1007/978-3-030-43620-9_10
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