How Does Pediatric Psoriasis Present?

Patient Presentation
A 14-year-old male came to clinic with a history of a new scalp lesion that had been present for 2 weeks. He had recently seen his barber who noticed the lesion and thought that it was psoriasis. The patient had not tried any treatment. He denied any new soaps, lotions, shampoos, acne or other skin or makeup products. He denied pain, pruritus or burning. The past medical history showed that he had scalp and facial seborrhea as an infant that lasted until 15 months of age. He occasionally had a dry scalp and needed to use a general dandruff shampoo in the winter. He also has general xerosis that was controlled by emollients. The family history was positive for atopic dermatitis. The review of systems showed he was healthy with no fevers, weight loss, arthralgias or infections.

The pertinent physical exam showed a healthy male with growth parameters in the 75-95%. The left parietal area had a 2.5 cm round lesion with thick yellow, greasy scale. There were no broken hairs or alopecia. There was mild erythema but no edema of the area. He had generalized xerosis, but no changes to his nails or umbilicus. The diagnosis of seborrhea was made. The patient was started on a topical steroid and a general selenium sulfide-containing dandruff shampoo to assist with the scale.

The patient’s clinical course over the next 3 weeks revealed that he had improvement but not complete resolution. There was no erythema and markedly decreased scale. He was changed to a tar-containing shampoo along with continued steroid therapy. Three weeks later, he had continued improvement but again not resolution and was referred to a dermatologist. The dermatologist performed a skin scraping confirming that this lesion was not tinea capitus and agreed that this was seborrhea. He was changed to a lotion-based steroid cream and a salicylic acid-containing shampoo. The lesion resolved over the next 6 weeks.

Discussion
Psoriasis is an inflammatory skin disease that is chronic and relapsing with periods of remission. It occurs in genetically susceptible persons and is felt to be triggered by environmental factors including infection (especially Group A, β-hemolytic streptococcus), emotional and physical stress, and skin irritation including friction, rubbing, pressure and scratching. It is common in patients with certain HLA types including HLA-Cw*0602, HLA-Cw6, IL-15 plus others.

It occurs in about 1% of the general population with two age-onset peaks: 16-22 years and ~60 years, but can occur at any age. Some studies show differences with girls/women more affected (2:1 over boys/men) and other studies do not support gender differences. Pediatric psoriasis patients are more likely to have a family history of psoriasis than adults.

Diagnosis is by clinical features and/or skin biopsy. Treatment is multimodal with education and psychosocial support being important component of this chronic disease. Many treatments in the US are used “off-label” in pediatric patients as they are not approved by the Federal Drug Administration for psoriasis in the pediatric age group. Treatment includes topical, phototherapy, and systemic treatment. Topical treatments include corticosteroids, calcineurin inhibitors, coal tar, keratolytics, retinoids, Vitamin D3 analogs and anthralin. Phototherapy with UVA and UVB can be used in various manners. Systemic treatments include cyclosporine, methotrexate, erythromycin, and various tumor-necrosis factors.

The general differential diagnosis of psoriasis includes:

  • Atopic dermatitis
  • Contact dermatitis
  • Pustular rashes
  • Pitarysis
  • Seborrhea
  • Tinea

In specific locations many other diagnoses may be included such as squamous cell carcinoma, oncomycosis, and blepharitis.

Learning Point
Common subtypes of pediatric psoriasis include:

  • Plaque
    • Silver-scaled, well-demarcated plaques
    • Usually on knees and elbow extensor surfaces but can occur in any skin area
    • This is the most common subtype – 34-84%
  • Scalp
    • If only occurring on scalp, may present with mild greasy and scaly plaques
    • Alopecia may be present
    • May be the site of initial presentation in 50% of patients
  • Face
    • Is more commonly involved with pediatric psoriasis than adult psoriasis
  • Diaper
    • Occurs in infants
    • Can occur in disseminated psoriasis
  • Guttate
    • Multiple, small, scaly papules
    • Occurs on extremities, trunk and sometimes face
    • Often triggered by Group A, β-hemolytic streptococcus
  • Pustular
    • Multiple papules occurring on erythematous skin
    • Papules may be localized or generalized
    • Papules are sterile
    • Often occurs with onset of fever and arthralgias

Other physical findings associated with psoriasis include nail pitting or other changes, mucosal ulcerations, geographic tongue and arthritis.

Questions for Further Discussion
1. What are the presentations of psoriatic arthritis?
2. What are the potential side effects of topical steroids?
3. What are the potential side effects of systemic treatment of psoriasis for pediatric patients?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for this topic: Psoriasis.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Bard S, Torchia D, Schachner LA. Managing pediatric patients with psoriasis. Am J Clin Dermatol. 2010;11 Suppl 1:15-7.

Sticherling M, Augustin M, Boehncke WH, Christophers E, Domm S, Gollnick H, Reich K, Mrowietz U. Therapy of psoriasis in childhood and adolescence – a German expert consensus. J Dtsch Dermatol Ges. 2011 Oct;9(10):815-23.

Shah KN. Diagnosis and treatment of pediatric psoriasis: current and future. Am J Clin Dermatol. 2013 Jun;14(3):195-213.

Meffert J. Psoriasis. Medscape. Available from the Internet at http://emedicine.medscape.com/article/1943419-differential (rev. 1/21/14, cited 2/21/14).

ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    7. All medical and invasive procedures considered essential for the area of practice are competently performed.
    8. Health care services aimed at preventing health problems or maintaining health are provided.
    9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Systems Based Practice
    23. Differing types of medical practice and delivery systems including methods of controlling health care costs and allocating resources are known.
    24. Cost-effective health care and resource allocation that does not compromise quality of care is practiced.

    Author

    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital

  • What Treatment is Available for Malaria?

    Patient Presentation
    A 17-year-old male came to the emergency room with a history of fever, chills, abdominal pain and headache for one day. The fever was to 102.5° and came and went. His headache was generalized and occurred mainly with the fever. His abdominal pain was more in the right upper quadrant with no radiation. He had nausea and therefore was not eating and was drinking less. The past medical and social history revealed he had recently come to the United State from eastern Africa. He said that he had had malaria several times in the past and the symptoms he was having were similar. The review of systems showed no dysuria with normal bowel and bladder function. He denied genital lesions or discharge, cough, rhinorrhea, or rashes.

    The pertinent physical exam showed a male in moderate distress who appeared mildly dehydrated. His abdominal examination showed a mildly tender liver that was 3-4 cm below his ribs. The rest of his examination was normal. The pertinent laboratory evaluation demonstrated increased liver enzymes with an AST of 307 U/L. His BUN was 45 mg/dl and his creatinine was 1.3 mg/dl. The hemoglobin was 14.3 mg/dl, platelets of 216 x 1000/mm2 and 1% schistocytes. His blood smear was positive for parasites (3%) that were eventually identified as Plasmodium falciparum. The radiologic evaluation of an abdominal ultrasound showed no appendicitis, normal kidneys and mildly increased liver size.

    The diagnosis of acute malaria was made. He was admitted to the floor but transferred to the ICU because of liver and renal function tests trending upward with hemoglobin and platelets trending downward over the next 18 hours. He was started on Coartem™ and quinine after consultation with the Centers for Disease Control. As one physician noted, “We don’t want to make mistakes with a disease that other doctors in the world with fewer resources treat and manage very well. We just don’t do this very often in the United States.” His condition stabilized and he was transferred to the floor on day 3. On day 4 he was almost afebrile, his liver enzymes had almost normalized, his hemoglobin was stable and his platelets were trending upward. Unfortunately, he had some emesis of his medication. Because there was a limited supply, he was changed to Malarone™ after consultation with the Centers for Disease Control. On day 5, he felt very tired but good, and he was discharged on day 6 to followup with the infectious disease specialist within the week with local lab testing in 2 days.

    Discussion
    Malaria is a life-threatening yet preventable and curable disease caused by parasites. In humans, there are 4 species that cause malaria: Plasmodium falciparum, Plasmodium vivax, Plasmodium malariae,and Plasmodium ovale. Plasmodium falciparum is the most deadly and Plasmodium falciparum and Plasmodium vivax are the most common. Plasmodium parasites are transmitted by bites from Anopheles mosquitoes from an infected human. The incubation period is 7-30 days. In 2012, it is estimated to have caused 627,000 deaths mostly among African children. Mortality rates have been decreasing but children, pregnant women, people with HIV/AIDs and immigrants and international travelers from non-endemic areas are most at risk. At risk is ~50% of the world’s population with ongoing transmission in 97 countries especially in sub-Saharan Africa, but also Asia, Latin America, the Middle East and Europe.

    Prevention is key. Insecticidal spraying and especially consistent use of long-lasting insecticidal mosquito nets are important strategies. There are problems with use of the nets including general wear. The World Health Organization is beginning research to evaluate real-world use of mosquito nets and potential strategies to increase their use and longevity. A vaccine is also being evaluated in clinical trials.

    Malaria is usually categorized into uncomplicated or severe disease. People with uncomplicated malaria usually will have fever, chills, sweats, headaches, body aches, nausea and emesis and fatigue/malaise. People with complicated malaria may have severe anemia, coagulopathies, acute respiratory distress syndrome, mental status changes kidney failure and/or hemoglobinuria, liver failure, signs of impending cardiovascular collapse such as hypotension, metabolic acidosis and hypoglycemia. Patients may present with any of these symptoms and/or signs of these problems such as acute mental status changes and jaundice or hepatomegaly with liver involvement.

    Learning Point
    Laboratory confirmed cases of malaria in the United States are reportable to local or state public health agencies. The Centers for Disease Control will provide help with diagnosis and treatment of suspected or confirmed cases by calling the CDC Malaria Hotline toll free at 770-488-7788, 855-856-4713 or 770-448-7100 (after hours).

    Malaria treatment depends on the area of the world the patient contracted the malaria in because of differences in the typical species of parasite and also potential antibiotic resistance to anti-malaria drugs. For uncomplicated malaria, the World Health Organization recommends use of oral artemisinin-based combination therapies for Plasmodium falciparum. It is always used in combination to help preserve its efficacy. One example is Coartem™ which is Artemether-lumefantrine. Other options recommended by the Centers for Disease Control in the United States include Malarone™ (atovaquone-proquanil) alone, or quinine plus either doxycycline, tetracycline or clincamycin. Mefloquine is also an option but one of the other 3 options is preferred. For severe malaria, the World Health Organization recommends patients be treated with injectable intramuscular or intravenous artesunate as the first line treatment. Artesunate followed by Malarone, doxycycline, clindamycin or mefloquine has an investigation new drug status in the United States and clinicians should contact the CDC for possible use. Another option recommended by the CDC is quinidine gluconate given IV, along with doxycycline, tetracycline, or clindamycin given IV or orally depending on the drug and if the patient is able to take oral medication.

    Questions for Further Discussion
    1. What species of malaria are common in your location?
    2. How effective have been malaria prevention techniques in your location?
    3. For patients traveling internationally to malaria endemia areas, how to you counsel them regarding malaria prevention?

    Related Cases

    To Learn More
    To view pediatric review articles on this topic from the past year check PubMed.

    Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

    Information prescriptions for patients can be found at MedlinePlus for these topics: Malaria and International Health.

    To view current news articles on this topic check Google News.

    To view images related to this topic check Google Images.

    To view videos related to this topic check YouTube Videos.

    Centers for Disease Control. Disease. Available from the Internet at: http://www.cdc.gov/malaria/about/disease.html#severe. (rev.2/8/10, cited 2/10/14)

    Centers for Disease Control. Guidelines for Treatment of Malaria in the United States. Available from the Internet at: http://www.cdc.gov/malaria/resources/pdf/treatmenttable.pdf (7/1/13, cited 2/10/14)

    Centers for Disease Control. Treatment of Malaria: Guidelines For Clinicians (United States)Part 2: General Approach to Treatment and Treatment of Uncomplicated Malaria Available from the Internet at: http://www.cdc.gov/malaria/diagnosis_treatment/clinicians2.html (7/13, cited 2/10/14)

    World Health Organization. Overview of malaria treatment. Available from the Internet at: http://www.who.int/malaria/areas/treatment/overview/en/index.html (rev. 3/6/13, cited 2/10/14)

    World Health Organization. Antimalarial drug efficacy. Available from the Internet at: http://www.who.int/malaria/areas/treatment/drug_efficacy/en/index.html (rev. 11/8/13, cited 2/10/14)

    World Health Organization. Factsheet on the World Malaria Report 2013. Available from the Internet at: http://www.who.int/malaria/media/world_malaria_report_2013/en/index.html (rev. 12/13, cited 2/10/14)

    WHO Malaria Policy Advisory Committee and Secretariat. Malaria Policy Advisory Committee to the WHO: conclusions and recommendations of September 2013 meeting. Malar J. 2013 Dec 20;12(1):456.

    World Health Organization. Malaria. Available from the Internet at: http://www.who.int/mediacentre/factsheets/fs094/en/index.html (rev. 12/2013, cited 2/10/14).

    ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    8. Health care services aimed at preventing health problems or maintaining health are provided.
    9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Practice Based Learning and Improvement
    12. Evidence from scientific studies related to the patients’ health problems is located, appraised and assimilated.
    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.
    14. Knowledge of study designs and statistical methods to appraisal clinical studies and other information on diagnostic and therapeutic effectiveness is applied.

  • Systems Based Practice
    23. Differing types of medical practice and delivery systems including methods of controlling health care costs and allocating resources are known.
    24. Cost-effective health care and resource allocation that does not compromise quality of care is practiced.

    Author

    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital

  • What Causes Ataxia?

    Patient Presentation
    A 33-month-old male was transferred to the inpatient unit with difficulty walking. One month ago he has Influenza A and one week ago he had diarrhea. Just before bed on the night before he seemed to walk a little funny but his maternal aunt thought that he was just tired. In the morning, the aunt saw that he was truly having problems walking and would fall backwards. He also seemed very fussy. He was taken to the local emergency room where his complete blood count, C-reactive protein, electrolytes, liver function tests, amylase and lipase, rapid strep test, urine toxicology screen and a head computed tomogram were negative. He was transferred to the regional children’s hospital for further evaluation. The past medical history was positive for otitis medias and colds. He received appropriate health supervision visits and had been developing normally. The review of systems was negative for rash, fever, with no changes in level of consciousness, and bowel or bladder. He was now refusing to eat and drink.

    The pertinent physical exam showed a fussy toddler with normal vital signs including blood pressure. His neurological examination showed significant ataxia with walking including a wide-based gait. When standing he had problems catching himself, would lean backwards and fall. He had truncal ataxia with sitting. There was normal vision, hearing and sensation. His DTR were +2 and he had normal strength. The work-up included an extended urine toxicology screen that was negative. His head magnetic resonance imaging and a lumbar puncture were normal. The diagnosis of acute cerebellar ataxia most likely due to a viral infection was made. Over the next few days, the patient was able to eat and drink more and became steadier on his feet. He was discharged and followed up with his local physician at one week who reported that he was able to sit and walk normally, but still would fall if he tried to run. At a followup neurology appointment at one month, his examination was normal. Infectious disease studies of the cerebral spinal fluid were unable to identify an organism.

    Discussion

    Coordination and balance problems are caused by various problems affecting the central and peripheral nervous system. Normal development of a child or weakness of a child are commonly mistaken for true ataxia. Ataxia specifically refers to “…impairment of the coordination of movement without loss of muscle strength.” If it is purely due to abnormalities of the cerebellum then there should be no changes in mental status, sensation or weakness. Sometimes it is difficult to determine if there are abnormalities in other areas. For example, Guillian-Barre often presents with difficulty or clumsy walking. Sometimes can be difficult with an uncooperative or scared young child to determine if there are sensation changes or weakness particularly early in the disease process. Therefore the child may be misclassified as having ataxia.

    Acute cerebellar ataxia was first described in 1868 by Shepherd. It has an acute onset that is usually followed by a complete recovery and good long-term prognosis. It is thought to be caused by an transient para- or post-infectious process but has not been specifically identified. Organisms that have been associated with acute cerebellar ataxia include:

      • Bacterial
        • Bordetella pertussis
        • Streptococcus, group A beta-hemolytic
        • Legionella
        • Mycoplasma
      • Viral
        • Epstein-Barr virus
        • Influenza
        • Hepatitis A and B
        • Herpes simplex
        • Measles
        • Mumps
        • Parvovirus B19
        • Polio
        • Varicella

    Patients present with acute ataxia with gross and fine motor problems. Resolution is within days to a few weeks but a small number of patients do have permanent problems.
    Treatment is supportive with watchful waiting. Physical therapy may help patients to cope with the symptoms.

    Learning Point
    The differential diagnosis of ataxia includes:

    • Acute
      • Acute cerebellar ataxia
      • Drug reaction, intoxication including lead
      • Encephalomyelitis, postinfectious
      • Head trauma – concussion, subdural hematoma
      • Hydrocephalus
      • Hysteria
      • Metabolic abnormalities – hypoglycemia, hypothyroidism
      • Meningitis (usually does not present solely with ataxia)
      • Tumor – posterior fossa
      • Labyrinthitis
      • Stroke
      • Weakness (mistaken for ataxia)
    • Chronic
      • Abetalipoproteinemia
      • Ataxia-telangectasia
      • Congenital anomalies of cerebellum
      • Friedrich’s ataxia
      • Hydrocephalus
      • Leigh’s syndrome (subacute necrotizing encephalopathy)
      • Tumor – posterior fossa

    Questions for Further Discussion
    1. What are indications for consultation with a neurologist for ataxia?
    2. What are indications for neuroimaging with ataxia?
    3. How does opsiclonus-myoclonus present?

    Related Cases

    To Learn More
    To view pediatric review articles on this topic from the past year check PubMed.

    Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

    Information prescriptions for patients can be found at MedlinePlus for this topic: Acute Cerebellar Ataxia

    To view current news articles on this topic check Google News.

    To view images related to this topic check Google Images.

    To view videos related to this topic check YouTube Videos.

    Illingworth RS. Common Symptoms of Disease in Children. Blackwell Scientific Publications: Oxford. 1988:17-19.

    Fleisher GR, Ludwig S. Synopsis of Pediatric Emergency Medicine. Williams and Wilkins. Baltimore, MD. 1996:49-52.

    Fogel BL. Childhood cerebellar ataxia. J Child Neurol. 2012 Sep;27(9):1138-45.

    Desai J, Mitchell WG. Acute cerebellar ataxia, acute cerebellitis, and opsoclonus-myoclonus syndrome. J Child Neurol. 2012 Nov;27(11):1482-8.

    ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.
    7. All medical and invasive procedures considered essential for the area of practice are competently performed.
    8. Health care services aimed at preventing health problems or maintaining health are provided.
    9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Systems Based Practice
    23. Differing types of medical practice and delivery systems including methods of controlling health care costs and allocating resources are known.
    24. Cost-effective health care and resource allocation that does not compromise quality of care is practiced.

    Author

    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital

  • How do Gifted Children Present?

    Patient Presentation
    An 8-year-old male came to clinic for his health supervision visit. His parents had no specific health related questions but they had questions about his schooling. He had taken a national test for 3rd grade students in the fall and he had qualified for the school’s gifted and talented program for the next year. The parents wanted to know if this was a good idea or “if this is just going to make him different from all the other kids.” The past medical history noted that he had been an early talker and reader and would play with plastic building blocks for hours never following the package instructions and making his own creations. His parents said he wore them out by asking “why?” all the time. The family history showed that the parents had finished college doing so on a part-time basis because of financial constraints. The father also was taking distance-learning classes.

    The pertinent physical exam revealed a healthy male with normal growth and vital signs. The diagnosis of a healthy male was made. The pediatrician said that the boy’s test scores seemed to be confirming what the parents probably already knew: that he was a talented individual who wanted to delve deeper into the world around him and learn more about it. He noted that this was what gifted and talented education programs are supposed to do is to provide for the needs of gifted students who can learn at a faster pace and deeper level compared to their peers. He also suggested that the parents set up a meeting with the program’s teacher to learn more about how it could benefit their son. As far as making him different, the pediatrician noted that this is a common myth that the children are very different than their peers socially. In most schools, children are moved between different groups and classrooms all the time to help meet the needs of all the children. Again, talking with the teacher to understand how this occurs in his school probably would be helpful. The pediatrician said, “It can be overwhelming sometimes to parent a gifted or talented child. It helps to learn more about it, so I’ll write down a couple of Internet websites where you can start to get more information. There are probably a few other parents in the school that you can talk with too. I also recommend that you take him to the library regularly. He’s old enough to look up information about what is interesting him and learn more about it. The librarian and you can guide him but he can do most of it. Plus the library is free to use.”

    Discussion
    One of the problems with understanding giftedness is the definition. The National Association of Gifted Children uses the following comprehensive definition:

      Gifted individuals are those who demonstrate outstanding levels of aptitude (defined as an exceptional ability to reason and learn) or competence (documented performance or achievement in top 10% or rarer) in one or more domains. Domains include any structured area of activity with its own symbol system (e.g., mathematics, music, language) and/or set of sensorimotor skills (e.g., painting, dance, sports).

    The United States Federal government uses a narrower, more educationally-focused definition:

      The term gifted and talented student means children and youths who give evidence of higher performance capability in such areas as intellectual, creative, artistic, or leadership capacity, or in specific academic fields, and who require services or activities not ordinarily provided by the schools in order to develop such capabilities fully.”

    To complicate the matter further, each state in the United States there is a different definition again primarily used for education.

    Data supports giftedness as genetic but also with ambition and opportunity being important factors in the long-term accomplishments of gifted individuals. Individuals can be identified early in life but variability of presentation is common and each child will not show giftedness in all areas. Some children will show their giftedness early and others may be late bloomers revealing their promise in adolescence. Individuals may also be gifted and have other learning disabilities or developmental or behavioral/psychiatric problems and are often referred to as “twice-exceptional.” These individuals may not be identified as gifted because their problems mask the giftedness. Conversely, the giftedness may mask their problems.

    For gifted children, encouraging their specific strengths and talents helps these children excel. For twice-exceptional individuals, supporting the problems while encouraging the giftedness provides the best opportunities for them to excel too. There are several common myths about gifted children including that academic acceleration is bad for gifted students when it should be considered for many individuals and there are rating scales to help with these decisions. Another myth is that many gifted individuals have psychiatric disorders when most are well adjusted children and adolescents.

    Learning Point
    Gifted children can present in a number of ways including:

    • Asynchrony across developmental domains
    • Advanced language and reasoning skills
    • Conversations and interests more aligned with older children and adults
    • Impressive long-term memory
    • Intuitive understanding of concepts
    • Ability to hold problems in mind that are not yet figured out
    • Insatiable curiosity
    • Advanced ability to connect disparate ideas, and appreciate relationships
    • Rapid learning
    • Heightened sensitivity and intensity of feelings and emotions
    • Perfectionism
    • Moral sensitivity
    • Advanced humor for age
    • Pleasure in solving and posing new problems
    • Capacity for independent, self-directed activities
    • Talents in specific areas (e.g. drawing, games, math, music, reading)

    Questions for Further Discussion
    1. How does your local school district accommodate gifted children in the classroom?
    2. What local resources are available to identify and assist gifted children and their families in your area?

    Related Cases

    To Learn More
    To view pediatric review articles on this topic from the past year check PubMed.

    Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

    Information prescriptions for patients can be found at MedlinePlus for these topics: Family Issues and School Health.

    To view current news articles on this topic check Google News.

    To view images related to this topic check Google Images.

    To view videos related to this topic check YouTube Videos.

    Pfeiffer SI. The gifted: clinical challenges for child psychiatry. J Am Acad Child Adolesc Psychiatry. 2009 Aug;48(8):787-90.

    Lubinski D. Exceptional cognitive ability: the phenotype. Behav Genet. 2009 Jul;39(4):350-8.


    Liu YH, Lien J, Kafka T, Stein MT. Discovering gifted children in pediatric practice. J Dev Behav Pediatr. 2010 Apr;31(3 Suppl):S64-7.

    National Association for Gifted Children. Redefining Giftedness for a New Century: Shifting the Paradigm. Available from the Internet at http://www.nagc.org/index.aspx?id=6404 (rev. 2010, cited 2/4/14).

    ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.

  • Practice Based Learning and Improvement
    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.

  • Interpersonal and Communication Skills
    18. Using effective nonverbal, explanatory, questioning, and writing skills, the healthcare professional uses effective listening skills and elicits and provides information.

    Author

    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital