A 10-month-old boy is brought to the office by his mother for a routine well-child visit. She says, "I'm planning on returning to work next month, but I'm worried about dropping him off at day care. Whenever someone tries to hold him, he cries and has screaming fits. He's gotten very clingy with me and my husband." The patient crawls, pulls to a stand, and says "Ma." The mother tries to feed him a range of foods, but he often refuses to eat certain vegetables. She says, "He just seems a bit fussier in general-my 4-year-old daughter was more easygoing at his age." The family moved from out of town 3 weeks ago for the mother's new job. During the evaluation, the patient sits quietly on his mother's lap but cries when he is picked up and weighed by the nurse. When the physician calls the patient's name, he turns his head away from the physician and looks at his mother. Physical examination is normal, and growth is at the 55th percentile. Which of the following is the most likely explanation for this patient's behavior?

Question

A 10-month-old boy is brought to the office by his mother for a routine well-child visit.  She says, "I'm planning on returning to work next month, but I'm worried about dropping him off at day care.  Whenever someone tries to hold him, he cries and has screaming fits.  He's gotten very clingy with me and my husband."  The patient crawls, pulls to a stand, and says "Ma."  The mother tries to feed him a range of foods, but he often refuses to eat certain vegetables.  She says, "He just seems a bit fussier in general-my 4-year-old daughter was more easygoing at his age."  The family moved from out of town 3 weeks ago for the mother's new job.  During the evaluation, the patient sits quietly on his mother's lap but cries when he is picked up and weighed by the nurse.  When the physician calls the patient's name, he turns his head away from the physician and looks at his mother.  Physical examination is normal, and growth is at the 55th percentile.  Which of the following is the most likely explanation for this patient's behavior?

Quizplus · Accepted Answer

This patient's behavior is most consistent with stranger anxiety, a normal part of early child development that is associated with learning to distinguish the familiar from the unfamiliar. Stranger anxiety typically starts at age 6 months, peaks at 8-9 months, and resolves by age 2 years. Children with stranger anxiety typically cry when an unfamiliar person approaches, even in the presence of the primary caregiver (as in this patient who cries in response to handling by the nurse even though the mother is present). This mother should be reassured that the patient's behavior is not pathologic and should improve over time; his stranger anxiety, fussiness compared with this sister, and food preferences are all within a normal range of behavior. (Choice A) Adjustment disorders are diagnosed when a behavioral or emotional response to a stressor is excessive or outside the realm of what is expected. Although stranger anxiety can be exacerbated by stress, such as with this family's move, it is a normal developmental milestone that would have occurred independently of the move. (Choice B) Although early signs of autism spectrum disorder may be present at this age, there is no evidence that this patient has deficits in social interaction or communication. He sits on his mother's lap, clings to her, and calls her "Ma," suggesting normal attachment and language development. In addition, there is no evidence that he has the restricted, repetitive patterns of behavior required for this diagnosis. (Choice D) Reactive attachment disorder occurs in children who have experienced neglect or abuse and develop insecure attachment to caregivers. It is characterized by a pattern of emotional and social withdrawal (eg, not crying in response to an unfamiliar person or separation from a parent). This patient's stranger anxiety is consistent with a normal, secure attachment to his mother. (Choice E) Separation anxiety (ie, anxiety when separated from the primary caregiver) is also part of normal development and typically resolves by age 2. It occurs only when separating from the parent, unlike stranger anxiety in which the distress occurs when the primary attachment figure is still present. Separation anxiety disorder is diagnosed in older children who exhibit extreme and persistent anxiety with separation and excessive worry about losing major attachment figures. Educational objective: Stranger anxiety is a normal part of development characterized by crying when an unfamiliar person approaches. It typically peaks at age 8-9 months and resolves by age 2 years. References: The development of stranger fear in infancy and toddlerhood: normative development, individual differences, antecedents, and outcomes. (http://www.ncbi.nlm.nih.gov/pubmed/24118713)

A 10-Month-Old Boy Is Brought to the Office by His