A 7-year-old boy is brought to the office by his parents for evaluation of behavioral concerns at school. The patient's father states, "He's repeating exactly what other kids say and can't seem to make any friends. Last year, he kept raising his hand but would say he was 'just stretching' when the teacher called on him. Luckily, he has stopped doing that." The patient says, "I try not to be bad, but sometimes I can't help it." He plays alone during recess to avoid bullying by other children and prefers to read books and complete jigsaw puzzles. Medical history is unremarkable. Family history is significant for obsessive-compulsive disorder in the father. Vital signs are within normal limits; height and weight are tracking consistently at the 60th percentile. Physical examination is unremarkable apart from frequent head turning and shoulder shrugging. On mental status examination, the patient appears remorseful and anxious. Which of the following is the most appropriate next step in management of this patient?

Question

A 7-year-old boy is brought to the office by his parents for evaluation of behavioral concerns at school.  The patient's father states, "He's repeating exactly what other kids say and can't seem to make any friends.  Last year, he kept raising his hand but would say he was 'just stretching' when the teacher called on him.  Luckily, he has stopped doing that."  The patient says, "I try not to be bad, but sometimes I can't help it."  He plays alone during recess to avoid bullying by other children and prefers to read books and complete jigsaw puzzles.  Medical history is unremarkable.  Family history is significant for obsessive-compulsive disorder in the father.  Vital signs are within normal limits; height and weight are tracking consistently at the 60th percentile.  Physical examination is unremarkable apart from frequent head turning and shoulder shrugging.  On mental status examination, the patient appears remorseful and anxious.  Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_d789_28f6_bc81_cd406176b91e_MD0003_00 This patient's presentation is consistent with Tourette syndrome (TS), characterized by multiple motor tics (eg, head turning, shoulder shrugging, hand raising) and at least one vocal tic (echolalia [ie, repetition of words]), which can wax and wane. More common in boys, TS typically presents at age 6-15. Nonpharmacological management of TS consists of habit reversal training, a form of behavioral therapy that increases tic awareness and teaches patients to perform a competing voluntary movement incompatible with the tic. When tics are severe and interfere with social and academic functioning, pharmacological treatment may be used. Options include dopamine antagonists (first- and second-generation antipsychotics), dopamine depleters (eg, vesicular monoamine transporter type 2 inhibitors such as tetrabenazine), and alpha-adrenergic agonists (eg, guanfacine, clonidine). When antipsychotic agents are used, second-generation antipsychotics (eg, risperidone, aripiprazole) are typically preferred over first-generation antipsychotics due to their more favorable adverse effect profile. (Choices A and D) Methylphenidate (stimulant) and atomoxetine (nonstimulant) are used for treatment of attention deficit-hyperactivity disorder (ADHD), which is comorbid with TS. This patient's behaviors (eg, hand raising, echolalia) reflect his tics rather than the fidgetiness and hyperactivity seen in ADHD; and his ability to play alone quietly, read books, and complete jigsaw puzzles makes ADHD unlikely. (Choices B and C) First-line treatment for obsessive-compulsive disorder (OCD), which is also comorbid with TS, is exposure and response prevention, a form of cognitive-behavioral therapy involving gradual and repetitive exposure to anxiety-provoking stimuli that produce obsessional thoughts, followed by prevention of performing the associated compulsion. Fluoxetine is a first-line pharmacotherapy of childhood major depressive disorder and OCD but is not effective in treating tics. The patient has multiple, waxing and waning involuntary tics not due to obsessional thoughts, most consistent with TS rather than OCD. (Choice E) Parent management training teaches parents to consistently implement behavioral strategies to shape behavior (eg, using rewards and nonpunitive consequences rather than punishment, setting limits calmly, having structured daily schedules). It has been used to treat oppositional defiant disorder (eg, persistent angry mood, defiant behavior, vindictiveness) and would not effectively target this patient's tics. Educational objective: Tourette syndrome is characterized by multiple motor tics and at least one vocal tic. Treatment options include habit reversal training and pharmacotherapy with antipsychotics, dopamine depleters, or alpha-adrenergic receptor agonists. References: Tourette syndrome: update. (http://www.ncbi.nlm.nih.gov/pubmed/25604739) Comprehensive systematic review summary: treatment of tics in people with Tourette syndrome and chronic tic disorders. (http://www.ncbi.nlm.nih.gov/pubmed/31061209)

A 7-Year-Old Boy Is Brought to the Office by His