A 9-year-old boy is brought to the office by his mother due to behavioral changes. The mother says, "He has always been an active child and can be loud at times; however, over the past few months, he has been more irritable. He usually gets along well with his classmates but got into a fight with one last week." The mother also notes that the patient gets upset in the mornings because he does not want to go to school. Since starting third grade 6 months ago, his academic performance has declined, and he has been making below average grades. A progress report from his teacher states that he does not participate in group activities and is unable to complete class assignments on time. When interviewed privately, the patient reports that his classmates call him a baby because he uses his fingers to count and reads slowly. He has no significant medical history. Vital signs are within normal limits; height and weight curves are tracking consistently. Physical examination shows no abnormalities. Which of the following is the most likely diagnosis in this patient?

Question

A 9-year-old boy is brought to the office by his mother due to behavioral changes.  The mother says, "He has always been an active child and can be loud at times; however, over the past few months, he has been more irritable.  He usually gets along well with his classmates but got into a fight with one last week."  The mother also notes that the patient gets upset in the mornings because he does not want to go to school.  Since starting third grade 6 months ago, his academic performance has declined, and he has been making below average grades.  A progress report from his teacher states that he does not participate in group activities and is unable to complete class assignments on time.  When interviewed privately, the patient reports that his classmates call him a baby because he uses his fingers to count and reads slowly.  He has no significant medical history.  Vital signs are within normal limits; height and weight curves are tracking consistently.  Physical examination shows no abnormalities.  Which of the following is the most likely diagnosis in this patient?

Quizplus · Accepted Answer

11ec25c8_d612_40d7_bc81_4daadb2bf6b6_MD0003_00 This patient's academic difficulties and behavioral issues related to school are most likely due to a specific learning disorder. Learning disorders are characterized by difficulty acquiring one or more core academic skills (eg, reading, writing, and/or mathematics) and manifest as academic achievement below the individual's potential. Learning disorders frequently come to attention with the stress of increasing academic demands and can contribute to the development of a negative self-concept, social anxiety, and behavioral issues. This patient's embarrassment at being a slow reader and using fingers to count are likely contributing to his reluctance to go to school, lack of class participation, irritability, and uncharacteristic conflict with peers. Learning disorders should be considered in any child with academic, behavioral, or social difficulties at school. Comprehensive evaluation includes educational testing, hearing and vision assessment, and ruling out other psychiatric (eg, anxiety, depression, attention deficit hyperactivity disorder) or neurologic/chromosomal disorders. Early intervention (eg, quality instruction, academic support and accommodations) can be helpful in improving self-esteem and social skills and preventing further academic decline. (Choice A) Attention deficit hyperactivity disorder can cause a decline in academic performance (eg, due to inattention) and associated behavioral difficulties. However, diagnosis requires a pattern of inattention and/or hyperactivity-impulsivity across at least 2 settings, whereas this patient's behavioral issues are limited to the school setting. (Choice B) Disruptive mood dysregulation disorder is characterized by persistently irritable or angry mood accompanied by repetitive temper outbursts (verbal or physical) that are out of proportion to the situation and the child's developmental level. It would not explain this patient's academic difficulties. (Choice C) Oppositional defiant disorder is characterized by a pattern of irritability, defiant behavior, and vindictiveness. This patient's behaviors are triggered in the school setting when his academic weaknesses are revealed. There is no indication that he is routinely defiant or argumentative. (Choice D) This patient's reluctance to go to school and discomfort around his peers are most likely secondary to fears of being teased about his learning difficulties. Social anxiety disorder is not diagnosed when anxiety and avoidance behavior are better explained by another disorder. Educational objective: A specific learning disorder (difficulties with key academic skills: reading, writing, and math) should be considered a diagnostic possibility in any school-aged child with academic, behavioral, or social difficulties at school. Early intervention can be helpful in improving self-esteem, social skills, and preventing further academic decline. References: Mental disorders and learning disabilities in children and adolescents: learning disabilities. (http://www.ncbi.nlm.nih.gov/pubmed/30556687)

A 9-Year-Old Boy Is Brought to the Office by His