An 11-year-old boy is brought to the office by his mother due to concerns about his anxiety and adjustment to school. Six months ago, he started a new school that requires him to change classrooms for different subjects. This has been stressful for him and has not become easier over time. He often gets in trouble because he forgets to raise his hand and blurts out answers. The patient reads at grade level and does well in math, but he has particular difficulty in classes that require oral participation or group projects. His mother says he has always been shy. He has no friends at school and can annoy others by talking incessantly about his interest in space exploration. The patient's behavior outside school causes problems as well. When morning traffic required departing from routine by taking a different route to school, he became agitated and refused to go. When interviewed, the patient looks away from the physician and interrupts him to recite the names of planets. Physical examination is remarkable for a repetitive opening and closing motion of his hands, which becomes more intense when he is asked about school, but is otherwise normal. Which of the following is the most likely explanation for the patient's behavior?

Question

An 11-year-old boy is brought to the office by his mother due to concerns about his anxiety and adjustment to school.  Six months ago, he started a new school that requires him to change classrooms for different subjects.  This has been stressful for him and has not become easier over time.  He often gets in trouble because he forgets to raise his hand and blurts out answers.  The patient reads at grade level and does well in math, but he has particular difficulty in classes that require oral participation or group projects.  His mother says he has always been shy.  He has no friends at school and can annoy others by talking incessantly about his interest in space exploration.  The patient's behavior outside school causes problems as well.  When morning traffic required departing from routine by taking a different route to school, he became agitated and refused to go.  When interviewed, the patient looks away from the physician and interrupts him to recite the names of planets.  Physical examination is remarkable for a repetitive opening and closing motion of his hands, which becomes more intense when he is asked about school, but is otherwise normal.  Which of the following is the most likely explanation for the patient's behavior?

Quizplus · Accepted Answer

11ec25c8_d79c_3be0_bc81_079bb7e95474_MD0003_00 This child's abnormal social development, insistence on sameness, and repetitive movements (opening and closing his hands) are suggestive of autism spectrum disorder (ASD). Changes in routines commonly cause anxiety and can provoke temper tantrums. Patients with high-functioning autism frequently have normal or near-normal language and intellectual ability that may account for delay in diagnosis (whereas more severe ASD is usually diagnosed by age 5). When social expectations increase with age, deficits in social awareness and social skills become more noticeable. Common features include inability to interpret and respond appropriately to nonverbal aspects of communication; abnormal eye contact; intense, perseverative interests and one-sided conversations about specific topics; difficulties understanding sarcasm, metaphors, or humor; and abnormal sensory sensitivity. (Choice A) Although this patient's social deficits have become more apparent with the increased demands of his new school, his difficulties are manifestations of ASD and not simply a time-limited response to a stressor. (Choice B) This child's blurting out of answers is likely due to his social deficits together with impulsivity, which are often seen in ASD. He does not display the overall picture of hyperactivity, impulsivity and impaired attention characteristic of attention-deficit hyperactivity disorder, which would warrant a separate diagnosis. (Choice D) Patients with obsessive-compulsive disorder can also present with obsessive interests and rigid adherence to specific routines. However, this patient lacks the intrusive obsessional thoughts and compulsive rituals performed in response to these thoughts required for this diagnosis. (Choice E) Although schizoid personality disorder involves a deficit in interpersonal relationships, it does not include the restricted interests and repetitive patterns seen in ASD. In addition, personality disorders are not diagnosed in children, as their personalities are still forming. (Choice F) This child's anxiety and avoidance of social interactions are primarily due to his deficits in social communication and not to a fear of embarrassment and social rejection, which can be seen in social anxiety disorder. (Choice G) Tourette syndrome is characterized by multiple motor and vocal tics. Vocal tics tend to be short, sudden noises or sounds rather than a blurting out of answers. Motor tics may resemble the stereotypical movements seen in ASD but are typically preceded by a premonitory urge. Educational objective: Autism spectrum disorder is characterized by abnormal social development and extreme behavioral rigidity, with onset in early development. Higher-functioning individuals with normal language and intellectual ability may be diagnosed later, when deficits become more apparent with increased social demands. References: Differentiating high-functioning autism and social phobia. (http://www.ncbi.nlm.nih.gov/pubmed/22038291) Effects of autistic traits on social and school adjustment in children and adolescents: the moderating roles of age and gender. (http://www.ncbi.nlm.nih.gov/pubmed/22960068)

An 11-Year-Old Boy Is Brought to the Office by His