A 5-year-old boy is brought to the office due to behavioral difficulties at school. His grandmother says, "This past year has not been easy for him, but he's been hitting other kids and breaking their toys." The patient was adopted by his grandmother a year ago after his parents died in a motor vehicle collision. He attends the same school but no longer wants to play with his friends or join group activities. The patient wakes up a few times a week, crying about monsters and asking to sleep in his grandmother's room. He can ride a bike and draw complex shapes. Vital signs are within normal limits, and he is tracking adequately on growth curves. Physical examination is unremarkable. The patient is restless and rams a toy truck into a stuffed animal repeatedly while his grandmother speaks. He makes poor eye contact and answers most questions by saying "I don't know" despite his grandmother's encouragement. Which of the following is the most likely diagnosis?

Question

A 5-year-old boy is brought to the office due to behavioral difficulties at school.  His grandmother says, "This past year has not been easy for him, but he's been hitting other kids and breaking their toys."  The patient was adopted by his grandmother a year ago after his parents died in a motor vehicle collision.  He attends the same school but no longer wants to play with his friends or join group activities.  The patient wakes up a few times a week, crying about monsters and asking to sleep in his grandmother's room.  He can ride a bike and draw complex shapes.  Vital signs are within normal limits, and he is tracking adequately on growth curves.  Physical examination is unremarkable.  The patient is restless and rams a toy truck into a stuffed animal repeatedly while his grandmother speaks.  He makes poor eye contact and answers most questions by saying "I don't know" despite his grandmother's encouragement.  Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

This child's recurrent nightmares, violent themes in play, emotional reactivity with aggressive play (eg, hitting, breaking), and social withdrawal after a traumatic loss are suggestive of posttraumatic stress disorder (PTSD). Exposure to trauma can occur through direct involvement in or witnessing of a traumatic event or by learning about violent trauma to a loved one. Young children with PTSD, whose memories may not be fully consolidated, often have nightmares that are not specific to the traumatic event (eg, monsters, being chased), as well as repetitive traumatic themes in play. They often struggle with emotional regulation and may appear easily upset or angered with little provocation. They may struggle with feelings of guilt, shame, or sadness. Other manifestations include dissociation (which may be mistaken for not paying attention); avoidance of places, people, or discussions related to traumatic incidences; difficulty concentrating; decreased interest in play; and social withdrawal, as seen in this patient. (Choice A) Social withdrawal and repetitive acts of aggression toward peers are not typical behaviors for a 5-year-old and warrant further evaluation. (Choice B) Difficulty with emotional regulation and resultant impulsivity are often seen in childhood PTSD and may be mistaken for attention deficit hyperactivity disorder (ADHD). However, this patient lacks evidence of the pervasive inattention and hyperactivity required for the diagnosis of ADHD, and this diagnosis alone would not explain his nightmares, social withdrawal, and aggressive themes in play. (Choice C) This patient lacks the restricted interests and stereotypical behaviors typically seen in autism spectrum disorder. His poor eye contact and reluctance to engage with the physician are more likely due to avoidance of discussing distressing topics rather than the deficits in social communication characteristic of this disorder. (Choice D) Oppositional defiant disorder presents with an irritable mood accompanied by vindictiveness and defiance of rules, which is deliberate in nature rather than a result of emotional distress. It would not explain repeated nightmares and traumatic themes in play. (Choice F) Reactive attachment disorder is an extreme outcome of early childhood abuse, which results in a lack of emotional responsiveness and the absence of comfort-seeking from caregivers. Educational objective: Posttraumatic stress disorder in children may present with distressing dreams with vague content and reenactment of traumatic themes in play, rather than clearly formulated memories. This is often accompanied by emotional dysregulation and behavioral difficulties. References: Pediatric PTSD in the DSM-5 and the forensic interview of traumatized youth. (http://www.ncbi.nlm.nih.gov/pubmed/28619857) Sleep disturbance in pediatric PTSD: current findings and future directions. (http://www.ncbi.nlm.nih.gov/pubmed/23674943)

A 5-Year-Old Boy Is Brought to the Office Due to Behavioral