Soft Neurological Signs in Young Children and My Personal Experiment

Dear Dr. Cason,

I have a son who is 4 and also a twin. He twitches his fingers and does this circular motion with his hands when he talks, but mostly when he is excited.(his arms stay at his side).My doctor says its just a nervous thing and that he will learn how to control it, but it worries me. What do you think?- CS

Dear CS-

It sounds like what you are describing is neurological overflow or what others will call "soft" neurological signs". These soft neurological signs are often used to describe signs that are either difficult to obtain or interpret. It is commonly seen in immature nervous systems of very young children. Persistence of these signs beyond a certain age though may indicate a future problem with attention and/or learning disorders or other cerebral dysfunctions.

You can test your child for soft neurological signs a couple of different ways.

1. Ask your child to walk across a room on their tip toes. As they perform this look for tremors and "overflow" involuntary movements that occur with his hands and his face.

2. Ask your child to touch the tip of their finger to the tip of your index finger and then touch the tip of their nose again. Do this three times. As they perform this look for tremors and "overflow" involuntary movements that occur with their other hand and their face.

Remember again, that the presence of these signs may or may not indicate future problems. The best thing you can do is discuss your concern with your pediatrician and if you are still concerned, they can refer you to visit with a pediatric neurologist who can evaluate your child and offer specific recommendations.

I hope this helps. I couldn't find any specific ages in which these soft signs should be gone. Most articles suggested that beyond age 5 or 6 was concerning for other conditions. Now as luck would have it I have a 4 and a 6 year old. They are both full term and otherwise developmentally on target.Tomorrow I shall do my own little experiment and let you know what I found!

*Warning* This is not a true "experiment" and one should take it as an interesting task and not necessarily indicative of how other 4-6 year olds will perform.

*11/18/08 Update*

Standing at the bus stop today I had a chance to test my children. The older 6 year old certainly did well. The four year old splayed her fingers a little as she touched her nose and had difficulty with balancing as she did the tip toe walk.I wouldn't necessarily call this a soft sign but she did show less coordination. I would expect her to get better at this and have no worries about her development overall.

I'd be curious what other people found out! Let me know by leaving me a comment.

What To Do When You Don't Like Your Doctor's Nurse

Dear Dr. Cason,

I just need some advice on a certain situation. My pediatrician used to have a fabulous nurse in the office that recently left and was replaced by a horribly incompetent one. She was awful at giving my 15 month old her shots and it really traumatized her, not to mention the needle came apart from the syringe as she injected one of them and the needle was stuck in my daughter's leg and some of the vaccine got on me instead of in my daughter. That's just one example of the horrible experience. What my question is, is how should I handle this situation? How would you prefer a mom to handle this situation if it was your nurse? I just really don't want this nurse to give my daughter any more shots. She has never been so traumatized by shots before, they have never been a big deal to her or me. I am already nervous about her next checkup. I want to handle the situation correctly but not get anybody in trouble. My pediatrician is just as caring as you are, so I would guess she would want the same actions taken that you would. Thanks so much for your time! - R



Dear R,

Oh no, that sounds like it wasn't a good moment for anyone! Situation like this happen all the time. I'm sure that there are many different ways you could handle the situation. For example you could go to the nurse and explain your concern or go directly to the office manager as they are trained to handle patient complaints. However the simplest thing is just to go directly to your child's pediatrician. She'll definitely want to know that something occurred and how she can best help you feel comfortable.

Don't rule out that this nurse may be very good and just have made a mistake. She also may be inexperienced and need more training. But then again she may truly be incompetent and need to be relieved of her duities. Having said all this, regardless of why it happened, someone needs to know so they can ensure that it doesn't happen again. I hope that this works out for you. Already it's stressful to bring your child in and watch them anxious but to worry if the nurse is doing the best of their ability is extra stressful.

Don't feel guilty about getting anyone in "trouble". As human beings we'll make mistakes and it's critical to receive constructive feedback. This is how we become better and grow as individuals and professionals. I do hope though at some point you'll talk directly to the nurse. She may have been having an off day and feel just as terrible as you do. I know that I've made mistakes and have been immensely grateful when I'm allowed the chance to make it better. If only just to say that I'm sorry.

Please let me know if I can be of any other help.

Sheila Cason MD

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Discussion Forum

I spend a lot of time talking and listening. It’s my profession! As a pediatrician I was trained to listen, ask questions, do a physical exam and mold all the information into diagnosis. I can’t help but give advice particularly if I feel something will harm a child. My children’s friends all hear my opinion on helmets and bike riding. I practice medicine every day because I love it. I love my patients- they make me laugh and smile. I love my patient’s families. I am inspired and awed by them. I love my colleagues. I love discussing cases and determining the best care for the children. All these people make me a better doctor and a better mom. I have dedicated my life to other parents’ children as well as my own. Often my two worlds collide. You can see that my pediatric advice is often peppered with my own experiences as a mother. I started my column because I knew there would be people that needed the advice. But I am also interested in hearing what you all think! Medrounds.org has started discussion forums that will facilitate the exchange of information. I welcome everyone to log on and participate!


Sheila Cason MD, FAAP