CCE-CBD-204

EXAMINER ONLY INFORMATION

QUESTIONS

Q1. How would you structure Liam’s 4-year-old health check?

• Prompt: What are the key components of a routine child health check?
• Prompt: How would you approach a developmental assessment?

Q2. How would you assess and interpret Liam’s developmental concerns?

• Prompt: What screening tools would you use?
• Prompt: How would you differentiate between normal variation and concerning findings?

Q3. Liam’s parents ask if he might have ADHD. How would you respond?

• Prompt: How do you assess attention and behaviour in a preschool-aged child?
• Prompt: What factors must be considered before making a diagnosis?

Q4. What recommendations would you make regarding Liam’s speech and behaviour?

• Prompt: When should he be referred for speech therapy?
• Prompt: What strategies can be implemented at home and preschool?

Q5. How would you counsel the parents on vaccination, dental care, and safety?

• Prompt: What vaccinations are due, and how do you address vaccine hesitancy?
• Prompt: What preventive health measures should be discussed at this age?

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Q1: How would you structure Liam’s 4-year-old health check?

A structured 4-year-old health check in Australian general practice follows the Medicare Benefits Schedule (MBS) Child Health Check guidelines and RACGP Red Book recommendations. It includes growth and development assessment, immunisation review, hearing and vision screening, and general health promotion.

1. History-Taking

• Birth and perinatal history: No complications at birth, full-term.
• Developmental history: Speech delay noted at 2.5 years, ongoing parental concerns.
• Social history: Attends preschool, some behavioural concerns raised by teachers.
• Family history: Father had childhood speech delay.
• Vaccination status: 4-year-old vaccines (DTPa-IPV, MMRV) overdue.
• Diet and nutrition: Assess dietary habits, including iron-rich foods.
• Physical activity: Screen for adequate play and movement.

2. Physical Examination

• Growth assessment: Plot weight, height, and BMI on growth charts.
• Developmental screening: Use the Ages & Stages Questionnaire (ASQ-3) and the Parents’ Evaluation of Developmental Status (PEDS).
• Hearing and vision: Conduct a pure tone audiometry and Snellen or LEA vision test.
• ENT examination: Check for chronic otitis media (possible cause of speech delay).
• General physical exam: Assess neurological status, tone, reflexes, and behaviour.

3. Screening and Preventive Health

• Vaccination: Explain the benefits of timely immunisation.
• Oral health: Screen for dental hygiene, refer if needed.
• Safety advice: Discuss sun safety, drowning prevention, and car seat use.

4. Parental Education and Next Steps

• Address parental concerns about speech and attention.
• Provide anticipatory guidance on expected behavioural development.
• Plan follow-up or referrals (e.g., speech therapy, audiology, developmental paediatrician).

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Q2: How would you assess and interpret Liam’s developmental concerns?

Liam’s developmental concerns primarily involve speech delay and attention difficulties, requiring a systematic approach based on RACGP guidelines for childhood development screening.

1. History-Taking

• Speech milestones: Expected clear speech and sentence formation by age 4.
• Behavioural concerns: Attention span, hyperactivity, and aggression noted at preschool.
• Hearing and otitis media history: Past ear infections may impact speech.
• Family history: Father had speech delay, raising genetic considerations.
• Social and environmental factors: Screen for adverse childhood experiences (ACEs).

2. Use of Validated Screening Tools

• Speech and language: PEDS, Receptive-Expressive Emergent Language Scale (REELS).
• General Development: Ages & Stages Questionnaire (ASQ-3).
• Behavioural screening: Strengths and Difficulties Questionnaire (SDQ).

3. Interpretation of Findings

• Red Flags: Lack of clear sentences, difficulty following instructions, inattention.
• Differential considerations:
  • Hearing loss: Recurrent otitis media history.
  • Neurodevelopmental disorder: ADHD or autism spectrum disorder (ASD).
  • Environmental factors: Limited exposure to language stimulation.
• Referral indications: Speech pathologist, audiology, developmental paediatrician.

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Q3: Liam’s parents ask if he might have ADHD. How would you respond?

ADHD cannot be formally diagnosed before age 6, but risk factors and early signs can be evaluated.

1. Acknowledge Parental Concerns

• Validate their observations and explain that some inattentiveness is developmentally normal.
• Provide reassurance that a full assessment is required before diagnosing ADHD.

2. Gather Additional Information

• Preschool reports: Check for consistent hyperactivity across settings.
• Validated screening tools: Use the Conners Early Childhood Rating Scale.
• Family history: ADHD has a strong genetic component.

3. Differential Considerations

• Normal variation: Some 4-year-olds have short attention spans.
• Speech delay impact: Language difficulties can mimic inattention.
• Hearing impairment: May cause difficulty following instructions.
• Emotional/social stressors: Family, trauma, or environmental factors.

4. Next Steps

• Early intervention: Support language development and structured routines.
• Observation over time: Monitor behavioural consistency across settings.
• Referral pathway: Consider paediatrician review if concerns persist.

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Q4: What recommendations would you make regarding Liam’s speech and behaviour?

1. Speech Therapy Referral

• Speech pathologist referral due to persistent speech delay.
• Home strategies: Reading, narrating daily activities, and expanding language exposure.

2. Behavioural Management

• Structured routines: Predictability helps attention regulation.
• Parental strategies: Positive reinforcement for good behaviour.
• Early childhood educator collaboration: Consistent strategies at preschool.

3. Audiology Review

• Assess for hearing loss, especially given recurrent otitis media history.

4. Developmental Follow-Up

• Monitor for progression over the next 6 months.
• Consider paediatrician referral if concerns persist.

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Q5: How would you counsel the parents on vaccination, dental care, and safety?

1. Vaccination Discussion

• Explain the importance of the 4-year-old vaccines (DTPa-IPV, MMRV).
• Address vaccine hesitancy if present.
• Offer catch-up schedule.

2. Dental Care

• Encourage twice-daily brushing with fluoride toothpaste.
• Advise first dental visit if not already attended.

3. Injury Prevention

• Car seat safety: Ensure booster seat use.
• Water safety: Supervision around pools.
• Sun protection: SPF 50+ and hat use.

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SUMMARY OF A COMPETENT ANSWER

• Structured child health check covering growth, development, and screening.
• Appropriate use of developmental screening tools (ASQ-3, PEDS, SDQ, etc.).
• Recognition of red flags for speech delay and attention concerns.
• Clear plan for referrals and ongoing monitoring.
• Effective parental communication, reassurance, and anticipatory guidance.

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PITFALLS

• Failing to use validated screening tools for developmental concerns.
• Overdiagnosing ADHD prematurely without considering differential diagnoses.
• Neglecting hearing assessment despite history of recurrent otitis media.
• Missing an opportunity to catch up on vaccinations.
• Not addressing parental concerns empathetically.

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REFERENCES

• 
  Australian Government Department of Health on Australian Immunisation Schedule
• Raising Children Network on Speech and Language Development in Children
• Royal Children’s Hospital Melbourne on Bedwetting Guidelines

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MARKING

Each competency area is on the following scale from 0 to 3.

☐ Competency NOT demonstrated
☐ Competency NOT CLEARLY demonstrated
☐ Competency SATISFACTORILY demonstrated
☐ Competency FULLY demonstrated

Competency at Fellowship Level

☐ CLEARLY BELOW STANDARD
☐ BELOW EXPECTED STANDARD
☐ BORDERLINE
☐ AT EXPECTED STANDARD
☐ ABOVE STANDARD