A 4-year-old boy is brought to the office due to unusual behavior and concerns about intellectual development. His parents state that "he doesn't speak a lot and doesn't seem to listen." They describe him as a slow learner who uses only single words and frequently mumbles. The patient is able to recognize a circle and the colors yellow and red, but he struggles to recognize other shapes and colors. He scribbles but does not draw lines. The patient crawled at 7 months and walked by 13 months. When he briefly attended preschool, he refused to speak at all and preferred to play with toy cars by himself. He was asked to leave the school due to daily temper tantrums in which he became hyperactive and banged his head with his hands when the teacher tried to redirect him. The patient was born at term from an uncomplicated pregnancy and delivery, and his physical growth has been normal. Weight and height are at the 50th percentile. During the examination, the patient refuses to speak with the physician and sits in the corner lining up toy cars. When his mother attempts to divert his attention from playing, he has a temper tantrum and begins to hit his head. A brief physical examination is normal. Which of the following is the most likely explanation for this child's behavior?

Question

A 4-year-old boy is brought to the office due to unusual behavior and concerns about intellectual development.  His parents state that "he doesn't speak a lot and doesn't seem to listen."  They describe him as a slow learner who uses only single words and frequently mumbles.  The patient is able to recognize a circle and the colors yellow and red, but he struggles to recognize other shapes and colors.  He scribbles but does not draw lines.  The patient crawled at 7 months and walked by 13 months.  When he briefly attended preschool, he refused to speak at all and preferred to play with toy cars by himself.  He was asked to leave the school due to daily temper tantrums in which he became hyperactive and banged his head with his hands when the teacher tried to redirect him.  The patient was born at term from an uncomplicated pregnancy and delivery, and his physical growth has been normal.  Weight and height are at the 50th percentile.  During the examination, the patient refuses to speak with the physician and sits in the corner lining up toy cars.  When his mother attempts to divert his attention from playing, he has a temper tantrum and begins to hit his head.  A brief physical examination is normal.  Which of the following is the most likely explanation for this child's behavior?

Quizplus · Accepted Answer

11ec25c8_d70d_90ab_bc81_451bb1144f40_MD0003_00 This child's speech delay, social isolation, repetitive stereotypical movements (eg, head banging), and fixated interest in cars are suggestive of autism spectrum disorder (ASD). ASD presents in early childhood and is 4 times more common in males. Lack of interest in shared social play and impaired joint attention (eg, lack of pointing or bringing objects to others) are characteristic of ASD. Odd repetitive behaviors (eg, lining up toys) and rigid adherence to routines (eg, distress over small changes) are also common. ASD can occur both with and without language and intellectual impairment. Language deficits can range from complete lack of speech to language delays and odd, stilted speech. (Choice B) Language disorder (ie, deficits in comprehension or production) presents in early childhood and can be difficult to diagnose due to considerable variability in language acquisition before age 4. However, nonverbal communication (eg, eye contact) should be normal. This child's lack of social interaction and restricted interests are more consistent with ASD. (Choice C) Although many patients with Fragile X syndrome display autistic behaviors, this child does not exhibit other features suggestive of the syndrome (eg, seizures, macrocephaly, hypotonia, long face, large ears). (Choice D) Global developmental delay is used to describe children under age 5 with delayed milestones in multiple intellectual areas and who are too young to undergo formal testing for intellectual deficits. In contrast to ASD, patients with global developmental delay still display social responsiveness and make efforts to communicate. (Choice E) Although this child engages in head banging, he does not display other characteristic self-mutilating behaviors or features typical of Lesch-Nyhan syndrome (eg, biting his fingers and tongue, dystonia, writhing movements, delayed motor development, nephrolithiasis, gout). (Choice F) In selective mutism, the child exhibits intact communication skills in certain settings (eg, school only) and not in others. Social reciprocity is not impaired even when the child is mute; restricted, repetitive behaviors are absent. (Choice G) Stereotypic movement disorder is diagnosed only when the stereotypies (repetitive, purposeless movements; eg, hand flapping, head banging) are not better explained by another disorder, such as autism in this child. Educational objective: Children with impaired social communication, restricted interests, and repetitive behaviors require assessment for autism spectrum disorder. Variable degrees of language and intellectual impairment may be present. References: Autism spectrum disorders. (http://www.ncbi.nlm.nih.gov/pubmed/23300017) Children with autism spectrum disorders who do not develop phrase speech in the preschool years. (http://www.ncbi.nlm.nih.gov/pubmed/25488002) Minimally verbal school-aged children with autism spectrum disorder: the neglected end of the spectrum. (http://www.ncbi.nlm.nih.gov/pubmed/24124067)

A 4-Year-Old Boy Is Brought to the Office Due to Unusual