A 10-year-old girl is brought to the office by her mother for evaluation of recent behavioral changes. The patient has been sleeping poorly and recently started wetting her bed. Her grades in school have dropped significantly, and she has been notably anxious and sad. The patient's parents are having financial difficulties and considering divorce. The father drinks alcohol most evenings after coming home from work. The mother appears stressed by her husband's drinking and is very concerned about her daughter. The physician has known the patient since she was a toddler and found her to be cheerful, lively, and cooperative at her checkup 6 months ago. After the mother leaves the room, the physician asks the patient about school and home, at which point she suddenly bursts into tears. After providing support, which of the following is the best next step in management of this patient?

Question

A 10-year-old girl is brought to the office by her mother for evaluation of recent behavioral changes.  The patient has been sleeping poorly and recently started wetting her bed.  Her grades in school have dropped significantly, and she has been notably anxious and sad.  The patient's parents are having financial difficulties and considering divorce.  The father drinks alcohol most evenings after coming home from work.  The mother appears stressed by her husband's drinking and is very concerned about her daughter.  The physician has known the patient since she was a toddler and found her to be cheerful, lively, and cooperative at her checkup 6 months ago.  After the mother leaves the room, the physician asks the patient about school and home, at which point she suddenly bursts into tears.  After providing support, which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_d74a_4bf7_bc81_d91cdfd216b5_MD0003_00 When working with vulnerable patients such as children, it is imperative that physicians be alert to any signs of possible abuse. Abuse must be ruled out in any child with abrupt onset of mood changes, bedwetting, and/or academic difficulties. Other factors associated with increased risk of abuse in this child include unstable family situation, financial difficulties, and caregiver history of substance abuse. Physical, sexual and emotional abuse should be considered early when evaluating mood and behavioral symptoms in children due to the high risk of recurrent abuse and the need for prompt intervention. The physician should ask the parent(s) to leave the room and provide a safe environment for the child to talk about her feelings and concerns. If abuse is confirmed or there remains a high index of suspicion of abuse, the physician is mandated to report it. (Choices B and F) Although encouraging the mother to attend a support group and initiating family therapy may be helpful, these would not take priority over assessing the patient for abuse. (Choice C) It is important to speak with the mother alone to get further details about the home environment, which she may not wish to reveal in front of her daughter. However, this does not take precedence over completing the interview with the patient and assessing for abuse. (Choice D) Changes in behavior and mood often occur in normal children in response to common psychosocial stressors such as divorce or parental discord. However, abuse must also be ruled out when a child has abrupt changes in mood, bedwetting, and academic decline. (Choice E) Cognitive-behavioral therapy has been studied for a number of psychological disorders in children and adolescents. Although it may have a role in the long-term management of this patient, psychotherapy would be a secondary priority and should not delay the urgent need to exclude abuse. Educational objective: Physicians should have a high suspicion for abuse in children with sudden changes in mood, behavior, or academic work, as well as in children with stressful family environments or parents with active drug/alcohol abuse. References: Audit of child maltreatment medical assessments in a culturally diverse, metropolitan setting. (http://www.ncbi.nlm.nih.gov/pubmed/29637146) Childhood sexual abuse: identification, screening, and treatment recommendations in primary care settings. (http://www.ncbi.nlm.nih.gov/pubmed/27262010)

A 10-Year-Old Girl Is Brought to the Office by Her