A 4-year-old boy is brought to the office for a routine visit. He has no medical problems and started preschool 3 weeks ago. The mother is concerned about his adjustment to school as he wants to stay home like his baby sister, frequently takes a long time to get dressed, and becomes upset when dropped off at school. On the first day of school, she was embarrassed when her son stomped his feet, yelled, "Take me home," and wrapped his arms around her legs, physically preventing her from leaving the classroom. The teacher reports that the boy settles down a few minutes after the mother leaves. He is shy but plays with the other children and participates in all class activities. The boy's sleep and appetite are normal, although he refuses to eat anything with peas in it. His growth and developmental milestones are within normal range. Which of the following is the most likely explanation for the boy's behavior?

Question

A 4-year-old boy is brought to the office for a routine visit.  He has no medical problems and started preschool 3 weeks ago.  The mother is concerned about his adjustment to school as he wants to stay home like his baby sister, frequently takes a long time to get dressed, and becomes upset when dropped off at school.  On the first day of school, she was embarrassed when her son stomped his feet, yelled, "Take me home," and wrapped his arms around her legs, physically preventing her from leaving the classroom.  The teacher reports that the boy settles down a few minutes after the mother leaves.  He is shy but plays with the other children and participates in all class activities.  The boy's sleep and appetite are normal, although he refuses to eat anything with peas in it.  His growth and developmental milestones are within normal range.  Which of the following is the most likely explanation for the boy's behavior?

Quizplus · Accepted Answer

This boy's initial protests and clinging behavior when he is dropped off at preschool are age-appropriate. Separation anxiety commonly develops at age 9-18 months and tends to improve with time, but it can recur during times of transition that require separation, such as attending school. Although this child is initially upset when being dropped off, he is able to settle down quickly, engages with other children, and participates in school activities. The transition to preschool can take some time, and the patient's desire to have his mother's attention at home and sibling rivalry with his baby sister are normal. (Choice A) Diagnosis of an adjustment disorder requires that symptoms exceed what would be expected given the nature of the stressor and result in impaired functioning. Neither is the case in this child. (Choice C) Oppositional defiant disorder involves a recurrent pattern of angry/irritable mood, argumentative/defiant behavior, or vindictiveness lasting at least 6 months. (Choice D) Parent-child relational problem is diagnosed when conflict in the parent-child relationship is beyond that seen in normal development and causes significant distress requiring clinical intervention. (Choice E) This patient has no evidence of separation anxiety disorder. Children with this disorder have extreme and persistent anxiety with separation and excessive worry about losing major attachment figures. They may have physical symptoms (eg, stomach aches, headaches), repeated nightmares involving the theme of separation, difficulty sleeping alone, and school refusal. (Choice F) Although this child is shy, he is able to interact with other children and participate in school activities. Children with social anxiety disorder are more avoidant and persistently anxious when having to engage throughout the day. (Choice G) Stranger anxiety is the fear of being around unknown people rather than fear of separation from parents and can occur with the parents in the room. It is developmentally appropriate beginning around age 6-12 months. Educational objective: Transient distress on initial separation from major attachment figures is age appropriate in children age 9-18 months and then again at times of transition, such as going to preschool. Children with persistent anxiety and distress at separation, repeated somatic complaints, or school refusal warrant further assessment. References: Childhood separation anxiety and the pathogenesis and treatment of adult anxiety. (http://www.ncbi.nlm.nih.gov/pubmed/24129927) Anxiety disorders and behavioral inhibition in preschool children: a population-based study. (http://www.ncbi.nlm.nih.gov/pubmed/24659133)

A 4-Year-Old Boy Is Brought to the Office for a Routine