A 7-year-old boy is brought to the office by his parents for an annual checkup. He is in 2nd grade, does well academically, and has no medical problems. His mother worries that he has no friends and prefers to play computer games by himself or spend time repeatedly organizing his extensive baseball card collection. On further questioning, she says that the boy moved to a new school this year because he was being bullied. The mother says, "He is different from the other kids and struggles to join in their games and conversations." She also mentions that he eats only 3 specific foods and has unusual food rituals. "He likes his glass to be filled to a certain level and doesn't want different foods touching each other on the plate." The father disagrees and says, "He's just a picky eater, like I was as a kid. Other kids can be mean; it's just part of growing up. It'll take time for him to get used to this new school and make friends." Developmental milestones are within normal range. There is no known psychiatric history. On examination, the boy makes poor eye contact and answers the physician's questions in a polite but formal manner. Physical examination and growth curves are normal. The father asks the physician to reassure his wife that nothing is wrong. Which of the following is the most appropriate course of action?

Question

A 7-year-old boy is brought to the office by his parents for an annual checkup.  He is in 2nd grade, does well academically, and has no medical problems.  His mother worries that he has no friends and prefers to play computer games by himself or spend time repeatedly organizing his extensive baseball card collection.  On further questioning, she says that the boy moved to a new school this year because he was being bullied.  The mother says, "He is different from the other kids and struggles to join in their games and conversations."  She also mentions that he eats only 3 specific foods and has unusual food rituals.  "He likes his glass to be filled to a certain level and doesn't want different foods touching each other on the plate."  The father disagrees and says, "He's just a picky eater, like I was as a kid.  Other kids can be mean; it's just part of growing up.  It'll take time for him to get used to this new school and make friends."  Developmental milestones are within normal range.  There is no known psychiatric history.  On examination, the boy makes poor eye contact and answers the physician's questions in a polite but formal manner.  Physical examination and growth curves are normal.  The father asks the physician to reassure his wife that nothing is wrong.  Which of the following is the most appropriate course of action?

Quizplus · Accepted Answer

11ec25c8_d7ea_0e07_bc81_3b5897dae2a2_MD0003_00 This patient's impaired social interaction, restricted interests, and insistence on routine raise concerns about autism spectrum disorder (ASD). Although many children are brought to clinical attention earlier (by age 5) and have some degree of language or intellectual disability, individuals on the mild end of the spectrum may present later when social deficits affecting peer relationships become more noticeable. The diagnosis of ASD is a clinical one, but it should ideally involve a comprehensive evaluation, including structured assessments of social, language, and intellectual development in addition to hearing, vision, and genetic (eg, fragile X syndrome) testing. These tests can aid in confirming the diagnosis and help procure and direct services. In this encounter, the physician must be sensitive to both parents (who have different views and levels of concern about their child) without alarming them. The best approach is to empathically listen to both parents' points of view while acknowledging the mother's concerns, educating the parents about the spectrum of developmental disorders, and recommending further evaluation to confirm the suspicion of ASD. (Choice A) This response is also likely to be alarming to the parents and erroneously advises against treatment. (Choice C) Although early intervention is important and improves outcome in ASD, this response is insensitive and alarming, especially given the father's perspective that nothing is wrong. The discussion should be sensitive to both parents and focus on education rather than treatment. (Choice D) The patient's behavior is longstanding and raises concerns for more than just an adjustment reaction to a new school. Although this response is diplomatic, it fails to address the concern about an autism spectrum disorder and may result in a delay in proper diagnosis and treatment. (Choice E) This response offers false reassurance. This boy's social deficits and restricted interests are significant and could lead to further bullying and the development of depression and anxiety. Educational objective: Autism spectrum disorder should be suspected in children with impaired social interactions, restricted interests, or repetitive behaviors. When parents have differing levels of concern, physicians should take a sensitive approach that considers both parents' views, educates them about the spectrum of developmental disorders, and encourages further evaluation. References: Autism spectrum disorders. (http://www.ncbi.nlm.nih.gov/pubmed/23300017) Effects of autistic traits on social and school adjustment in children and adolescents: the moderating roles of age and gender. (http://www.ncbi.nlm.nih.gov/pubmed/22960068) Parents' concerns as they relate to their child's development and later diagnosis of autism spectrum disorder. (http://www.ncbi.nlm.nih.gov/pubmed/27541581)

A 7-Year-Old Boy Is Brought to the Office by His