An 11-year-old boy is brought to the office by his mother for assessment of behavioral issues. His mother explains that he has "not been himself" since starting middle school a few months ago. The patient has become increasingly argumentative with his parents and becomes irritable with his siblings for no clear reason. He spends most of his time in his bedroom and comes out only to eat dinner, quickly returning to his room after only a few bites. He watches TV late into the night due to restlessness, struggles to fall asleep, and then complains that he is tired the next day. The patient used to regularly attend soccer practice and spend time with friends afterward but recently said that he is "bad at" the sport and wants to quit the team. A teacher has expressed concern that his grades have dropped from a B to a C average, that he is not engaged in class, and that his work has become "sloppy." When interviewed without his mother present, the patient says, "I just wish people would leave me alone." The patient does not use alcohol or illicit drugs. Vital signs are normal, and physical examination shows no abnormalities. He makes poor eye contact and fidgets with his clothes. Which of the following is the most likely diagnosis in this patient?

Question

An 11-year-old boy is brought to the office by his mother for assessment of behavioral issues.  His mother explains that he has "not been himself" since starting middle school a few months ago.  The patient has become increasingly argumentative with his parents and becomes irritable with his siblings for no clear reason.  He spends most of his time in his bedroom and comes out only to eat dinner, quickly returning to his room after only a few bites.  He watches TV late into the night due to restlessness, struggles to fall asleep, and then complains that he is tired the next day.  The patient used to regularly attend soccer practice and spend time with friends afterward but recently said that he is "bad at" the sport and wants to quit the team.  A teacher has expressed concern that his grades have dropped from a B to a C average, that he is not engaged in class, and that his work has become "sloppy."  When interviewed without his mother present, the patient says, "I just wish people would leave me alone."  The patient does not use alcohol or illicit drugs.  Vital signs are normal, and physical examination shows no abnormalities.  He makes poor eye contact and fidgets with his clothes.  Which of the following is the most likely diagnosis in this patient?

Quizplus · Accepted Answer

This pediatric patient's behavioral changes, marked by an irritable mood and withdrawal from social activities together with poor sleep, poor appetite, impaired concentration, and psychomotor agitation (restlessness, fidgeting), are consistent with major depressive disorder (MDD). As children move into adolescence and explore their autonomy and identity, they may engage in limit-testing and a desire to spend time with peers rather than family. However, a marked change from baseline, with social withdrawal from peers and declining academic performance, as in this case, should prompt concern for a primary psychiatric illness and not be dismissed as age-appropriate behavior (Choice E). Pediatric depression may present with symptoms of irritability, annoyance, and argumentative behavior rather than depressed mood. Identification and appropriate treatment are important to decrease distress and limit impairment in social, emotional, and academic development, as well as to decrease the risk of suicide. (Choice A) Although starting middle school can be a significant stressor, the severity of symptoms and degree of impairment in this patient make MDD more likely than adjustment disorder. Adjustment disorder is not diagnosed when the criteria for another psychiatric disorder, such as MDD, are met. (Choice B) Attention-deficit hyperactivity disorder would not explain this patient's poor sleep, poor appetite, or social withdrawal. Impaired concentration, distractibility, and psychomotor changes (agitation in this case) are common manifestations of depression. (Choice C) In disruptive mood dysregulation disorder, patients also have irritable mood. However, this is accompanied by repetitive temper outbursts (verbal or physical) that are out of proportion to the stimulus and inconsistent with developmental level. Symptoms manifest prior to age 10. (Choice F) Oppositional defiant disorder presents with an irritable or angry mood accompanied by deliberately annoying behavior, defiance of rules, and vindictiveness. It would not explain poor sleep, poor appetite, or social withdrawal. This child's defiance is likely a result of his irritability rather than being deliberate in nature. Educational objective: Pediatric major depression may present with irritability rather than depressed mood. If a patient displays irritability along with social withdrawal and academic decline, major depression should be considered. References: Screening for depression in children and adolescents: U.S. Preventive Services Task Force recommendation statement. (http://www.ncbi.nlm.nih.gov/pubmed/26858097)

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