A 6-year-old boy is brought to the clinic by his mother due to behavioral concerns. Several months ago, the parents divorced. Over the past month, the mother has noticed that the patient has become increasingly inattentive, which has affected his school and home life. At school, his first-grade teacher has noticed that he often stares into space, blinking for several seconds. Some students in his class have teased him because of this behavior. On several occasions at home, while helping to set the dinner table or while cleaning his room, he would pause. When questioned by his mother, the patient would ignore her, blankly staring before resuming the task. During physical examination, he is pleasant, talkative, and interactive. Neurologic examination shows intact cranial nerves. The patient has normal strength, sensations, and reflexes bilaterally. Gait is normal and Romberg test is negative. This patient would most likely benefit from which of the following?

Question

A 6-year-old boy is brought to the clinic by his mother due to behavioral concerns.  Several months ago, the parents divorced.  Over the past month, the mother has noticed that the patient has become increasingly inattentive, which has affected his school and home life.  At school, his first-grade teacher has noticed that he often stares into space, blinking for several seconds.  Some students in his class have teased him because of this behavior.  On several occasions at home, while helping to set the dinner table or while cleaning his room, he would pause.  When questioned by his mother, the patient would ignore her, blankly staring before resuming the task.  During physical examination, he is pleasant, talkative, and interactive.  Neurologic examination shows intact cranial nerves.  The patient has normal strength, sensations, and reflexes bilaterally.  Gait is normal and Romberg test is negative.  This patient would most likely benefit from which of the following?

Quizplus · Accepted Answer

11ec25c8_d6fd_63ed_bc81_f3b02c53fae6_MD0003_00 This patient has brief episodes of impaired concentration (eg, pause, blank stare) that occur in multiple settings with a sudden onset and resolution. These episodes are suggestive of absence seizures, which are generalized seizures that typically last <20 seconds and occur in children age 4-10. During these episodes, which are often mistaken for inattention, patients maintain postural tone but are unresponsive to vocal or tactile stimulation. Motor automatisms during the seizure are common and can include oral (eg, lip smacking, chewing) or eyelid (eg, blinking, fluttering) movements. Many patients have a personal history of febrile seizures and/or a family history of seizures. Hyperventilation can trigger an episode, but baseline neurologic examination is normal. Diagnosis of absence seizures is confirmed by demonstration of a classic 3-Hz spike and wave pattern on electroencephalogram. Ethosuximide is the first-line therapy. Most patients can discontinue medication before puberty with no long-term sequelae. (Choice A) Cognitive behavioral therapy (commonly used for depression, anxiety, and phobias) is a form of psychotherapy that focuses on reframing maladaptive thinking and on teaching coping mechanisms. Although this patient's social concerns (ie, teasing by classmates) should be addressed, his symptoms are not suggestive of a psychiatric diagnosis. (Choice C) Attention-deficit hyperactivity disorder (ADHD) treatment may include stimulant medications (eg, methylphenidate). Patients with the inattentive subtype of ADHD often experience staring spells; however, these spells are responsive to vocal or tactile stimulation. In addition, patients with ADHD often display forgetfulness, difficulty with organization, and easy distractibility (none of which are seen here). (Choice D) Modafinil is a treatment for narcolepsy. In contrast to this case, patients with narcolepsy have cataplexy, characterized by loss of postural tone with preservation of consciousness that is usually emotionally triggered (eg, laughing). (Choice E) Reassurance is appropriate for nonepileptic staring spells, which are interruptible by external stimuli and not associated with automatisms. In addition, unlike absence seizures, nonepileptic staring spells typically last >1 minute. Educational objective: Absence seizures typically occur in children age 4-10 and are characterized by <20-second episodes of impaired concentration (eg, pause, blank stare) with preserved postural tone. Automatisms (eg, blinking, lip smacking) are common, and ethosuximide is the first-line treatment. References: Absence seizure. (http://www.ncbi.nlm.nih.gov/pubmed/29763042)

A 6-Year-Old Boy Is Brought to the Clinic by His