A 5-year-old girl is brought to the office due to behavioral changes. The mother says, "We took her to a magic show a few months ago and bought a toy wand from the gift shop. Now she thinks she has special powers." The patient brings the wand to school each morning so that "bad things don't happen." A week ago, she forgot to bring her wand home, and that night, her father was in a motor vehicle collision that resulted in a fractured wrist. The patient says, "Dad got hurt because of me. It was my fault." She has become more protective of the wand and no longer shares it with her classmates because "it will lose its power." Each night before falling asleep, the patient closes her eyes and taps her wand in the air 3 times to make sure she and her family stay safe. Vital signs are within normal limits; growth curves are tracking consistently. Physical examination shows no abnormalities. Which of the following is the most likely diagnosis?

Question

A 5-year-old girl is brought to the office due to behavioral changes.  The mother says, "We took her to a magic show a few months ago and bought a toy wand from the gift shop.  Now she thinks she has special powers."  The patient brings the wand to school each morning so that "bad things don't happen."  A week ago, she forgot to bring her wand home, and that night, her father was in a motor vehicle collision that resulted in a fractured wrist.  The patient says, "Dad got hurt because of me.  It was my fault."  She has become more protective of the wand and no longer shares it with her classmates because "it will lose its power."  Each night before falling asleep, the patient closes her eyes and taps her wand in the air 3 times to make sure she and her family stay safe.  Vital signs are within normal limits; growth curves are tracking consistently.  Physical examination shows no abnormalities.  Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

This girl's belief that her magic wand can directly influence events around her is characteristic of magical thinking, a normal phase of cognitive development in children age 2-7. During this phase, children often combine fantasy elements taken from toys and entertainment with real life events. They can have strong beliefs in the magical powers of objects and the existence of imaginary characters (eg, tooth fairy, fantasy characters, imaginary friends). This girl's belief that she directly caused her father's injury by forgetting her wand is also an example of the egocentric thinking that characterizes normal cognitive development during these years; young children often see an event as it relates to themselves only and may feel responsible when something bad happens. This girl should be reassured that her behavior in no way caused her father's accident. The parents should be reassured that magical thinking is a normal developmental stage that may help children face their fears, resolve conflicts, and develop their imagination and creative thinking. (Choice A) Adjustment disorders are characterized by emotional or behavioral disturbances that are out of proportion to precipitating stressors and are functionally impairing. This child's behavior is age appropriate, and there was no obvious precipitant stressor that preceded her belief in the wand's magic powers. Her reaction to her father's accident is also consistent with normal cognitive development. (Choice C) Pediatric obsessive-compulsive disorder (OCD) is characterized by time-consuming repetitive compulsions performed in response to obsessional thoughts. This girl's bedtime ritual is performed only once and is connected to her age-appropriate magical thinking. In addition, onset of pediatric OCD is typically in middle, rather than early, childhood. (Choice D) Although magical thinking can be seen in patients who go on to develop schizotypal personality disorder, it would typically be accompanied by a persistent pattern of unusual perceptual experiences, eccentric behavior, and excessive social anxiety. This child's magical thinking is developmentally appropriate and likely to be outgrown. (Choice E) Although separation anxiety disorder involves fears of harm to major attachment figures, this patient is attending school without difficulty and does not have excessive distress with separation. Educational objective: Young children often engage in magical thinking, involving beliefs in the magical powers of objects and the existence of imaginary characters. It is a normal phase of cognitive development in children age 2-7. References: Cognitive development. (http://www.ncbi.nlm.nih.gov/pubmed/30725780)

A 5-Year-Old Girl Is Brought to the Office Due to Behavioral