An 8-year-old boy is brought to the pediatrician for school refusal. He has not gone to school for a few days, saying that he has a stomachache. However, when it comes time for soccer practice, he has no physical symptoms. When the pediatrician asks how things are going at school, the patient says, "kids laughed at me when the teacher said she couldn't read my homework." His mother brings a recent report from the boy's teacher, which says that he is able to read and do math, but that when writing he fidgets a lot and stares out the window. His writing is unclear, disorganized, and below the level of his peers. His mother received a call from his teacher last week after the boy threw his writing book on the floor and began to cry. Vital signs and physical examination, including abdominal examination, are normal. At this time, which of the following is the most likely diagnosis in this patient?

Question

An 8-year-old boy is brought to the pediatrician for school refusal.  He has not gone to school for a few days, saying that he has a stomachache.  However, when it comes time for soccer practice, he has no physical symptoms.  When the pediatrician asks how things are going at school, the patient says, "kids laughed at me when the teacher said she couldn't read my homework."  His mother brings a recent report from the boy's teacher, which says that he is able to read and do math, but that when writing he fidgets a lot and stares out the window.  His writing is unclear, disorganized, and below the level of his peers.  His mother received a call from his teacher last week after the boy threw his writing book on the floor and began to cry.  Vital signs and physical examination, including abdominal examination, are normal.  At this time, which of the following is the most likely diagnosis in this patient?

Quizplus · Accepted Answer

A learning disorder is characterized by difficulties with key academic skills (reading, writing, or mathematics). Problems manifest at school age when these skills are being acquired, and performance is well below average for age. Many children display symptoms of anxiety, inattention, defiance, or hyperactivity when under stress to perform in an area of weakness, as exemplified by this child's struggle to pay attention and his emotional outburst in class. Learning disorders are often comorbid (eg, writing plus reading). In addition to academic dysfunction, they can also impact social skills and self-confidence. Definitive diagnosis requires comprehensive assessment, including educational testing and ruling out intellectual disability, hearing or vision impairment, and other psychiatric or neurological disorders. Providers should consider the possibility of a learning disorder in any child presenting with school difficulty. Early intervention can be helpful in improving self-esteem and preventing further disability. (Choice A) Attention-deficit hyperactivity disorder is characterized by inattention and/or hyperactivity-impulsivity across at least 2 settings. There is no indication that this child struggles with inattention or hyperactivity when asked to read or do math or that this is a problem in the home setting. (Choice B) Language disorder presents with difficulties in acquiring and using language, which manifests in speaking as well as written language. (Choice C) Intellectual disability begins in early development and includes deficits in general mental abilities and adaptive functioning. Specific learning disorders occur in the presence of normal levels of intellectual functioning. (Choice D) In oppositional defiant disorder, there is a pattern of anger or irritability, argumentativeness, and defiant behavior. This patient's school refusal and throwing a book are in the context of stress. There is no indication that he is routinely defiant or argumentative. (Choice E) This patient enjoys playing soccer, and his school refusal is more likely due to fears of being teased. A diagnosis of social anxiety disorder requires persistent symptoms ≥6 months. This boy's learning disorder should be addressed to avoid further social anxiety. (Choice F) In somatic symptom disorder, anxiety revolves around a patient's symptoms. This boy is not anxious about his stomachache; his stomachache is a manifestation of his anxiety about school. Educational objective: Learning disorders are characterized by difficulties with key academic skills (reading, writing, or mathematics), resulting in performance well below expectations for age. Providers should consider a possible learning disorder in any school-aged child with behavioral, academic, or social difficulties at school. __________ References: Critical issues in the understanding of young elementary school students at risk for problems in written expression: introduction to the special series. (http://www.ncbi.nlm.nih.gov/pubmed/28498735) Specific learning disorder: prevalence and gender differences. (http://www.ncbi.nlm.nih.gov/pubmed/25072465) Specific learning disorders and ADHD: current issues in diagnosis across clinical and educational settings. (http://www.ncbi.nlm.nih.gov/pubmed/25894357)

An 8-Year-Old Boy Is Brought to the Pediatrician for School