Pediatric Neurological Examination for the Psychiatrist

Steven M. Wolf

Patricia Engel Mcgoldrick

Lee Cohen

This chapter should assist psychiatrists in detecting medical or neurological disorders that may masquerade as psychiatric ones. Among the children who present for psychiatric evaluation, some inevitably have symptoms or signs that may indicate an underlying neurological problem. Psychiatrists should be familiar enough with the neurological evaluation—whether they or a consultant neurologist performs it—to identify abnormal findings and to order appropriate testing.

The Neurological Examination

The neurological examination traditionally begins with assessment of the chief complaint, including changes in cognition, emotions, or behavior; slowing of development in a previously normal child; and loss of previously acquired milestones in growth and development. Physicians usually elicit the patient’s medical history, including hospitalizations (medical and psychiatric), age at onset of the presenting symptoms, surgeries, illnesses, past and current medications, learning disabilities, and social history. In evaluating children, especially those who are developmentally delayed, the physician’s pertinent questions include a full birth history with specific questions regarding whether (a) the child was full term (and if not, how premature); (b) the pregnancy was complicated by drug or alcohol abuse, illnesses, or trauma; (c) the infant experienced neonatal seizures, respiratory arrest, or hypoxic ischemic events; (d) any diagnosis was made of a neonatal stroke or intraventricular hemorrhage; or (e) the postnatal period was complicated by infections, seizures, trauma, or other potential insult. The physician should gather the results of prior neurological tests, such as ultrasound of the head, magnetic resonance imaging (MRI) of the brain and spine, and determinations of blood levels of amino acids and organic acids. The physician usually also inquires about a family history of epilepsy, psychiatric diagnoses, regression, mental retardation, consanguinity, and neurodegenerative disorders. The physician should also be particularly concerned about siblings with similar or other illnesses.

Pediatric neurologists usually begin the physical portion of the examination by noting the child’s physical development (height, weight, and head size), appearance, and exposed skin surface. Then the physician assesses the child’s behavior, thought processes, and thought content. As part of the mental status examination, physicians assess the child’s affect, ability
to respond to commands, and response to questions. Depending on the problem at hand, the physician may inquire about mood, visual or auditory hallucinations, illusions, delusions, and suicidality. The physician generally tests the child’s higher functions, such as attention; short- and long-term memory; calculations; abstract thought; spatial, visual, and body perception; and praxis (ability to perform complex movements).

The physical portion of the examination begins with observation of the shape and size of the child’s head, with attention to symmetry. For children younger than 2 years, examiners should measure and graph the circumference of the child’s head on a normative graph. The head should be palpated for areas of tenderness and skeletal defect, and in young children, sutures and fontanelles should be assessed by palpation. The anterior fontanel closes usually at 12 to 18 months of age, whereas the posterior fontanel closes earlier, before 6 months of age. The ridges of the sutures (coronal, lambdoidal, metopic, and sagittal) should not be palpable. The examiner should also note asymmetry of the head. Flattening of the back of the head (found in infants and young children who spend much time lying on their backs) indicates plagiocephaly. If the head shape is more indicative of a parallelogram, the examiner should be concerned about craniosynostosis (premature closure of one or more of the sutures). Although plagiocephaly is usually managed by keeping the child off his or her back, the suspicion of craniosynostosis requires assessment with a three-dimensional computed tomography (CT) scan and immediate referral to a neurologist and neurosurgeon.

The examination then progresses to testing the cranial nerves (CNs) (Table 1.1), which are evaluated in the following manner: Inquire about a loss of the sense of smell, which usually suffices to evaluate CN I without formal testing. Looking at the level of the eyes, search for asymmetry of the eyelids, ptosis, and note whether the eyes are sunken (enophthalmic) or protruding (exophthalmic). Assess the pupils’ symmetry, alignment, and response to light and accommodation. Observe the child’s face for symmetry, lesions, and abnormal movements. Always test hearing by determining responses to spoken and whispered speech. Check lower CN function by asking the child to protrude and move the tongue, and observe palate movement.

Musculoskeletal Examination

Examination of the musculoskeletal system often gives important clues to neurological system abnormalities. Strength is tested in the upper extremities by having the child squeeze the examiner’s hands. The child should then be asked to flex the arms and provide resistance as the examiner tries to pull the arms down and forward. To test the complementary muscles, the examiner asks the child to flex his or her arm muscles and push the examiner away.

In addition, the examiner, taking the child’s hand as if to shake it, should pronate and supinate the forearm, and then roll the hand at the wrist. The examiner should check the arms for wasting and fasciculations and ask the child to extend his or her arms to check for involuntary movements (pronator test).

To test the lower extremities, the child should be seated with legs dangling and asked to raise the legs, with knees bent at a 90-degree angle, against resistance from the examiner’s hand. Strength in both legs should be equal. The child should then be asked to kick against the examiner’s hand. In this test, the examiner should separately test each leg. Again, strength should be equal. With the child relaxed, the examiner should check for hypertonicity or hypotonicity and for spasticity. In addition, the child should lie with legs
straight, and the examiner should roll the knee from side to side, and then rapidly flex and extend the lower leg at the knee. Similarly, holding the foot and lower leg, the examiner should flex and extend (plantar flex and dorsiflex) the child’s foot. Normal tone is defined by slight resistance occurring through the whole range of movements; increased tone, by marked resistance; and decreased tone, by no resistance.

TABLE 1.1 EXAMINATION OF CRANIAL NERVES

Cranial Nerve	Function	Testing
I Olfactory	Sense of smell	Identify fruit, peppermint, ammonia (test each nostril separately).
II Optic	Vision, afferent arc of light reflex	Perform funduscopy (observe the disc’s color, disc margins, optic cup, blood vessels). Evaluate visual fields. Determine visual acuity (use Snellen chart or available reading material).
III Oculomotor	Eye movements, pupillary response, efferent arc of pupillary reflex	Check vertical and horizontal movements, and then accommodation.
IV Trochlear	Inward-torsion eye movement	Test with CN III.
V Trigeminal	Sensory: ophthalmic (V₁), maxillary (V₂), and mandibular (V₃) sensation	Determine jaw-muscle strength. Check facial sensation and corneal reflex. Look for wasting of temporalis muscles.
	Motor: muscles of mastication
VI Abducens	Lateral eye movement	Test with CN III.
VII Facial	Muscles of facial expression; stapedius; taste; tearing	Observe nasolabial folds, and determine strength of opening and closing eyelids.
VIII Acoustic	Hearing	Using tuning fork, perform Rinné and Weber tests.
IX Glossopharyngeal	Taste, salivary response	Check taste, salivation.
X Vagus	Sensory: tympanic membrane, external auditory canal and external ear	Check gag reflex and palate elevation.
	Motor: muscles of palate, pharynx, larynx
	Autonomic: carotid innervation
XI Accessory	Sternocleidomastoid and trapezius muscles	Observe neck-muscle strength by turning head side to side and shrugging shoulders against force.
XII Hypoglossal	Tongue muscles	Determine tongue movements, bulk, and deviation.
CN, cranial nerve.

Examination of Reflexes

Deep tendon reflexes (DTRs) commonly tested in the office include those listed in Table 1.2

Examination of Gait

Of all the clinical assessments of the physical portion of the nervous system, none is more valuable than observing the child’s gait. As the child walks into the examination room, the physician has the first opportunity to look for any indication of a neurological disorder.

TABLE 1.2 COMMONLY TESTED DEEP TENDON REFLEXES

Reflex	Innervation	How to test
Biceps	C5	The examiner should flex the child’s arm at the elbow, swing the reflex hammer onto the child’s biceps tendon, and watch the biceps muscle contract.
Triceps	C7	The examiner should draw the child’s arm across the chest and, with the elbow at 90 degrees, strike the triceps tendon with reflex hammer, and watch the triceps muscle contract.
Brachioradialis	C6	The examiner should flex the child’s arm onto the abdomen. Placing the finger on the radial tuberosity, the examiner should hit the finger with the reflex hammer and watch the brachioradialis muscle contract.
Patellar	L3L4	With the child’s legs dangling, the examiner should strike the knee below the patella and watch the quadriceps muscle contract.
Achilles	S1	The examiner should hold the child’s foot at 90 degrees, strike the Achilles tendon, and watch the calf muscle contract.
Babinski		Draw a sharp edge from the heel up and below the toes on the sole of the foot. The abnormal response, the Babinski sign, consists of extension of the big toe with fanning of the other toes. However, this is a normal response in infants, usually disappearing by age 2 years.
C, cervical; L, lumbar; S, sacral.

Because a normal gait depends on intact and delicately balanced motor, sensory, and coordination systems, a normally walking child probably has little or no impairment in the physical portions of the nervous system. Physicians should observe the child’s gait for symmetry, size of paces, posture, arm swing, and smoothness of movements. Tandem gait should be assessed by having the child walk heel-to-toe, as if walking a tightrope. The examiner should also ask the child to walk on his or her heels and then toes. Having the child stand upright with arms outstretched, eyes closed (Romberg testing), will assess joint-position sense. The examiner can then gently push the child to see if he or she can maintain balance. If the child does not, a Romberg sign is said to occur. Table 1.3 lists common gait abnormalities.

TABLE 1.3 COMMON ABNORMALITIES OF GAIT

Description of Gait	Possible Diagnosis
Small paces, stooped posture, and reduced arm swing, with difficulty starting and stopping	Basal ganglia dysfunction, as seen in childhood Parkinson, Wilson, and juvenile Huntington diseases
Scissoring gait: adducted, straight legs	Spastic paraparesis, as in cerebral palsy, MS, spinal cord compression
Waddling gait	Weak proximal hip-girdle muscles, as in muscular dystrophy and other myopathies, and congenital hip dislocation
Bizarre, elaborate, inconsistent (including astasia-abasia)	Psychogenic disturbances
Ataxia: broad-based, lurching	Cerebellar dysfunction, as in drug or alcohol intoxication, MS, hereditary ataxias, posterior fossa tumor
Sensory ataxia with positive Romberg sign	Loss of joint-position sense, as in peripheral neuropathy or posterior column impairment; cerebellar disease
Hemiplegic gait: one leg swings out straight to side (circumduction)	Unilateral upper motor neuron disease, as in cerebral palsy, stroke, MS, or traumatic brain injury
Foot drop	Weakness on ankle dorsiflexor muscles, as in common peroneal palsy, L5 radiculopathy, peripheral neuropathy
MS, multiple sclerosis.

Abnormalities of Skin

Examiners look at children’s skin for diagnostic clues. For example, petechiae may be indicative of a blood dyscrasia; striae may suggest Cushing disease or use of steroids; and “birthmarks” may indicate the presence of a neurocutaneous disorder. Because embryological ectoderm gives rise to both the central nervous system and the skin, many conditions—neurocutaneous disorders—consist of a cutaneous abnormality with an underlying neurological component. The examiner should undress the child and observe the skin for lesions that may indicate a neurocutaneous disorder. Physicians should note the distribution, size, and color of any lesion, and determine whether a change in its appearance has occurred (Table 1.4). They should always be on alert for signs of the above.

Helpful Clues on Examination

Although the examiner may use these physical findings to formulate a differential diagnosis and to order tests, the potential severity of an illness and the likelihood of its presence will determine whether further evaluation should be performed on an emergency basis.

Symptoms and examination findings that require immediate evaluation are the following:

Severe headaches—worst of the patient’s life, awakening from sleep, accompanied by vomiting, occurring in the early morning
Inability to walk
Unresponsiveness
CN findings (abnormalities on examination)
Apathy, depression of new onset, especially coupled with decline in performance

Symptoms that require neurological evaluation, but not as an emergency, include these:

Abnormal gait (speak to a pediatric neurologist regarding whether to order radiographs of the spine or an MRI scan of the lumbosacral spine if a sacral dimple or hair tuft is found)
Precocious puberty (order an MRI scan of the brain to rule out pituitary abnormalities)
New onset of incontinence (discuss symptoms with a neurologist, especially regarding whether an imaging study and other referrals are needed)
Back pain (MRI of the painful area usually can be performed while awaiting referral)
Weakness of one or more extremities [new onset requires referral; longstanding weakness without any previous testing may require MRI of the brain or spinal cord or electromyography (EMG)]
Regression, including worsening of a previously diagnosed learning disability or attention deficit disorder [order an MRI scan of the brain; electroencephalogram (EEG); and metabolic workup, including urine for organic acids and toxicology, as well as blood for lactate, pyruvate, ammonia, and organic acids]
Sudden change in vision (including loss of central or peripheral vision, onset of nystagmus, development of CN abnormalities) (order an MRI scan of the brain and orbits, and solicit an ophthalmology consultation)
Change in gait (possibly consult with orthopedist)
Change in level of consciousness (usually refer to the emergency room)
Episodic events (for repeated, transient changes in the level of consciousness, delusion, hallucinations, or illusions, because they represent seizure activity, order an MRI scan of the brain and EEG)
Headaches [if headaches occur more frequently than three times per week, without an obvious cause, such as lack of sleep or inadequate oral intake, consider an MRI scan of the brain and blood tests.

TABLE 1.4 LESIONS

Diagnosis	Type of Lesion	Color	Appearance	Distribution
Neurofibromatosis	Café-au-lait spots	Light-pigmentation masses	Flat	Axillary and groin freckling, Lisch nodules in iris, neurofibromas, and café-au-lait spots anywhere on the body
	Lisch nodules
	Neurofibromas
Tuberous sclerosis	Shagreen patch	Hypopigmented	Rough, irregular	Usually back, but can be anywhere
	Adenoma sebaceum	Brown	Raised	Malar region
Sturge-Weber syndrome	Vascular facial birth marks	Port-wine stain and facial capillary angiomas	Flat	Trigeminal distribution