A 4-year-old boy is brought to the office by his father for a well-child visit. The father says, "He gets frustrated so easily when I can't understand what he's saying. He'll throw himself on the floor, screaming and crying. I thought he would have outgrown this by now." The father also reports that the patient is having trouble at preschool. His teacher has mentioned that he does not speak much in class, is difficult to understand, and cries loudly when upset. The patient can balance on one foot, catch a ball, cut with scissors, and draw a square. He speaks in 2- or 3-word phrases and is unable to name colors or letters. On interview, the patient's speech is clear but difficult to understand. He says, "School open Monday; not dog today." When the physician asks, "You are not going to school today?" the patient starts crying and throws his toys on the floor. Physical examination, audiologic testing, and laboratory evaluation are normal. Which of the following is the most likely diagnosis in this patient?

Question

A 4-year-old boy is brought to the office by his father for a well-child visit.  The father says, "He gets frustrated so easily when I can't understand what he's saying.  He'll throw himself on the floor, screaming and crying.  I thought he would have outgrown this by now."  The father also reports that the patient is having trouble at preschool.  His teacher has mentioned that he does not speak much in class, is difficult to understand, and cries loudly when upset.  The patient can balance on one foot, catch a ball, cut with scissors, and draw a square.  He speaks in 2- or 3-word phrases and is unable to name colors or letters.  On interview, the patient's speech is clear but difficult to understand.  He says, "School open Monday; not dog today."  When the physician asks, "You are not going to school today?" the patient starts crying and throws his toys on the floor.  Physical examination, audiologic testing, and laboratory evaluation are normal.  Which of the following is the most likely diagnosis in this patient?

Quizplus · Accepted Answer

Several aspects of this patient's presentation are consistent with a language disorder (LD), including his difficulty making himself understood in multiple settings (eg, home, school) and his inability to name colors or letters. LD becomes evident in early development due to a deficit in understanding and/or producing language. LD can present with a limited vocabulary, inaccurate sentence structure, or difficulty using language to explain concepts or create a story. Children who have difficulty verbalizing their needs often express frustration in other ways (eg, temper tantrums) or attempt to have their needs met through physical aggression (eg, hitting, grabbing). Early recognition and intervention for LD is critical for improving outcomes. LD in a preschooler may also be the precursor of academic difficulties that lead to later diagnosis of a specific learning disorder in a school-age child. Diagnosis of a specific learning disorder requires standardized testing that identifies specific deficits in academic disciplines such as reading, written expression, and mathematics (Choice F). (Choice A) This child is attempting to communicate with others, whereas in autism spectrum disorders (ASD) children display limited social interest. He also lacks the restricted interests and repetitive behaviors seen in ASD. (Choice B) Disruptive mood dysregulation disorder is characterized by an irritable or angry mood with repeated temper tantrums that are out of proportion to the stimulus and inappropriate for developmental level. Because temper tantrums are common in young children, the diagnosis should not be made prior to age 6. This child's tantrums are likely the result of him being misunderstood rather than related to generalized irritability or anger. (Choice C) In order to diagnose global developmental delay, deficits in multiple areas of intellectual functioning are required. Apart from a language delay, this child's developmental milestones are on target. developmental milestones (Choice E) This child's verbal milestones are delayed and should not be dismissed as normal. By age 4, children should be able to name at least 2 colors, and their speech should be intelligible. Educational objective: Language disorder becomes evident in the early developmental period when a child has difficulty acquiring and/or using language appropriately. It can result in behavioral difficulties and negatively impact later academic achievement. References: The pediatrician's role in optimizing school readiness. (http://www.ncbi.nlm.nih.gov/pubmed/27573085) Emotional and behavioural problems in children with language impairments and children with autism spectrum disorders. (http://www.ncbi.nlm.nih.gov/pubmed/25039810)

A 4-Year-Old Boy Is Brought to the Office by His