A 3-year-old boy is brought to the office by his mother due to "inattentiveness." Medical history is significant for preterm birth at 35 weeks, 4 ear infections in the past year, and mild eczema. Vaccinations are up to date and a hearing screening performed 8 months earlier was normal. Family history is significant for asthma in the patient's father, anxiety in his mother, and attention-deficit hyperactivity disorder (ADHD) in his older brother. The patient's mother reports that when asked to perform tasks at home, he ignores her and continues to do whatever he is engaged in. He has become more withdrawn lately and often sits in the corner alone playing with rockets instead of playing with his brother. His poor attention span has worsened over the last few months, and his mother wonders if it is related to anxiety about starting preschool 3 months ago. Apart from lack of attention, he is described as an "affectionate, active little boy who loves to run around and loves his pets." Physical examination reveals a small child who responds only intermittently to the physician's directions. The patient is able to draw a square and stand on 1 foot. He speaks in brief phrases of 2 or 3 words, which is similar to his presentation 6 months ago. Neurological examination is normal. Growth curves are tracking just under the 50th percentile for stature and weight. Which of the following is the best next step in management of this patient?

Question

A 3-year-old boy is brought to the office by his mother due to "inattentiveness."  Medical history is significant for preterm birth at 35 weeks, 4 ear infections in the past year, and mild eczema.  Vaccinations are up to date and a hearing screening performed 8 months earlier was normal.  Family history is significant for asthma in the patient's father, anxiety in his mother, and attention-deficit hyperactivity disorder (ADHD) in his older brother.  The patient's mother reports that when asked to perform tasks at home, he ignores her and continues to do whatever he is engaged in.  He has become more withdrawn lately and often sits in the corner alone playing with rockets instead of playing with his brother.  His poor attention span has worsened over the last few months, and his mother wonders if it is related to anxiety about starting preschool 3 months ago.  Apart from lack of attention, he is described as an "affectionate, active little boy who loves to run around and loves his pets."  Physical examination reveals a small child who responds only intermittently to the physician's directions.  The patient is able to draw a square and stand on 1 foot.  He speaks in brief phrases of 2 or 3 words, which is similar to his presentation 6 months ago.  Neurological examination is normal.  Growth curves are tracking just under the 50th percentile for stature and weight.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

This patient's inconsistent response to the physician's questions, trouble following directions, and lack of progression of language skills is concerning for hearing impairment. Hearing impairment in children can be due to a variety of causes, both hereditary and acquired. The most common cause is conductive hearing loss due to repeated ear infections. Hearing impairment can be mistaken for other behavioral or pervasive developmental disorders. If undetected, it can lead to poor language development, lack of social skills, and self-isolation. Although this child's 3-year audiometry screening was normal, he has had multiple ear infections in the last year, making repeat audiometry testing necessary to assess for acquired hearing loss. (Choice A) Although social isolation and poor communication skills can be seen with autism spectrum disorders, this child does not have the repetitive behaviors or behavioral rigidity that are characteristic of autism, making it less likely. Hearing loss should be ruled out first. (Choices B and F) Delayed language can be seen with genetic or metabolic conditions, although more global developmental delay, including motor, cognitive, and social delays, would be expected. In addition, this patient lacks other features of metabolic or genetic conditions such as dysmorphic features, hypotonia, neurological deficits, seizures, or organ dysfunction. If repeat audiometry testing is normal, then additional testing could be pursued. (Choice C) Parent and teacher behavioral evaluations are important in the diagnosis of attention-deficit hyperactivity disorder (ADHD), which requires evidence of impairment in multiple domains. Children with hearing impairments often appear inattentive and impulsive and may be incorrectly diagnosed with ADHD. However, poor language development and social isolation are not features of ADHD, and hearing impairment should be ruled out before this diagnosis is considered. (Choice D) A formal speech and language assessment is an important part of the workup for communication and language disorders. However, it should be done only after a hearing assessment has ruled out hearing loss. (Choice E) This patient's history is not suggestive of seizures. An EEG can be used to rule out Landau-Kleffner syndrome, an epileptic condition that presents with regression in language milestones after normal development. Educational objective: Repeated ear infections can result in conductive hearing loss, which may be confused with certain pervasive and behavioral disorders of childhood. Hearing tests should be routinely conducted in all children presenting with social or language deficits. References: Hearing assessment in infants and children: recommendations beyond neonatal screening. (http://www.ncbi.nlm.nih.gov/pubmed/19786460) Hearing loss in children with otitis media with effusion: a systematic review. (http://www.ncbi.nlm.nih.gov/pubmed/27841699)

A 3-Year-Old Boy Is Brought to the Office by His