A 9-year-old girl is brought to the office by her mother due to behavioral problems at school. The patient was sent home a week ago after she threw a pencil and cried when the teacher criticized her handwriting. Since that time, she has had stomachaches every morning and asks to stay home. Her recent report cards describe her as "having trouble focusing; easily upset when she makes a mistake." The mother says, "For the past year, she has become increasingly self-conscious and can't seem to relax. She always thinks that she will say something stupid and that the other kids will laugh at her. When I try to reassure her, she becomes irritable and snaps at me." At home, the patient completes her homework and chores without prompting, and her appetite is normal. A few nights a week, she struggles to fall asleep due to concerns that someone might break into the house and insists that her mother check the locks. The patient has no significant medical history, but family history is notable for depression in her mother. Physical examination is normal. The patient is easily distracted by noises outside the room and repeatedly fidgets with her clothing. Which of the following is the most likely diagnosis?

Question

A 9-year-old girl is brought to the office by her mother due to behavioral problems at school.  The patient was sent home a week ago after she threw a pencil and cried when the teacher criticized her handwriting.  Since that time, she has had stomachaches every morning and asks to stay home.  Her recent report cards describe her as "having trouble focusing; easily upset when she makes a mistake."  The mother says, "For the past year, she has become increasingly self-conscious and can't seem to relax.  She always thinks that she will say something stupid and that the other kids will laugh at her.  When I try to reassure her, she becomes irritable and snaps at me."  At home, the patient completes her homework and chores without prompting, and her appetite is normal.  A few nights a week, she struggles to fall asleep due to concerns that someone might break into the house and insists that her mother check the locks.  The patient has no significant medical history, but family history is notable for depression in her mother.  Physical examination is normal.  The patient is easily distracted by noises outside the room and repeatedly fidgets with her clothing.  Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

11ec25c8_d7cb_d787_bc81_f9bd93b2047d_MD0003_00 This patient's excessive concern about multiple issues (her work not being good enough, kids laughing at her, intruders in the house), resulting in irritability (snapping at her mother, throwing pencils), difficulty falling asleep, and poor concentration, is suggestive of generalized anxiety disorder (GAD). GAD in children can manifest as a need for perfectionism and order; when these are not attainable, coping difficulty is also seen (eg, this patient's emotional outburst after being criticized at school). Other manifestations include somatic symptoms (eg, stomachache, school refusal). Although the diagnosis of GAD in adults requires uncontrollable worry accompanied by ≥3 additional symptoms (eg, restlessness, fatigue, irritability), only 1 additional symptom is required in children and adolescents. (Choice B) Although this patient fears intruders and asks her mother to check the locks, she does not display the time-consuming (eg, >1 hour a day) intrusive thoughts and/or repetitive, ritualistic behaviors required for a diagnosis of obsessive-compulsive disorder. (Choice C) Obsessive-compulsive personality disorder is characterized by a long-standing, pervasive need for control and order at the expense of efficiency and flexibility. This patient gets upset when she makes mistakes but can complete tasks (eg, homework, chores) on time. Also, personality disorders require stability over time and are not diagnosed during childhood. (Choice D) In oppositional defiant disorder, defiance is willful rather than due to anxiety and is accompanied by a pattern of argumentativeness and vindictive behavior. (Choices E and F) This patient has anxiety about multiple issues, including the quality of her work, whether other children like her, and safety at home. Her anxiety is not centered around separation from her mother, as in separation anxiety disorder, or focused solely on a fear of negative evaluation, as in social anxiety disorder. Educational objective: Generalized anxiety disorder presents with excessive concern about a range of issues, which can result in irritability, poor sleep, and trouble concentrating. Children with anxiety commonly experience somatic symptoms. References: Generalised anxiety disorder in children and adolescents. (http://www.ncbi.nlm.nih.gov/pubmed/26763675)

A 9-Year-Old Girl Is Brought to the Office by Her