A 14-year-old girl is brought to the clinic due to behavioral changes over the last 2-3 months. She has become increasingly angry and easily annoyed, arguing with teachers at school and her mother at home and refusing to do her chores. The patient was previously an honor roll student, but her grades have dropped significantly and she is now failing most subjects. When asked why her grades have dropped, the patient says, "It's been really hard to focus on what the teacher is saying and I have trouble remembering to turn in my homework." Her mother reports that the girl has gained 18.1 kg (40 lb) in the last 3 months. The patient's father is currently unemployed and abuses alcohol. To help with finances, the family moved in with the girl's aunt and uncle 9 months ago. The patient became sexually active 3 months ago, has had 4 lifetime partners, and uses no birth control. She smokes marijuana several times a week but does not use tobacco or alcohol. BMI is 33 kg/m². On mental status examination, the patient appears fidgety and avoids eye contact during the examination. She still enjoys playing with her little brother and has no thoughts of death or suicide. Which of the following is the most likely explanation for this patient's change in behavior?

Question

Quizplus · Accepted Answer

Explanation: This patient's marked change in behavior after moving into a relative's home is suggestive of child abuse. Victims of child abuse are at high risk for psychological disturbances (eg, inattention, impulsivity, mood changes, appetite and sleep disturbances) that may mimic other disorders such as attention-deficit hyperactivity disorder (ADHD), oppositional defiant disorder, and depression. New sexual behaviors are particularly concerning for sexual abuse. This patient's recent onset of irritability, argumentativeness, risky sexual behavior with multiple partners, and impaired concentration with resulting decline in academic performance should raise strong concern that she is being sexually abused. Child abuse should always be considered in the differential diagnosis of childhood emotional and behavioral symptoms, as failure to do so may lead to further harm to the child and inappropriate treatment. Abuse victims are at increased risk for developing psychiatric disorders and should be referred for psychological assessment and age-appropriate counseling. (Choice A) This patient's recent lack of focus and forgetfulness are better explained as complications of trauma. In addition, a diagnosis of ADHD requires onset of symptoms before age 12 with a duration of >6 months and would not explain this patient's other symptoms (eg, high-risk sexual behavior). (Choice C) This patient's irritability, impaired concentration, weight gain, and academic decline are consistent with major depressive disorder. However, she is still able to enjoy playing with her brother and lacks 5 of 9 symptoms required for diagnosis (depressed mood, anhedonia, sleep disturbances, appetite change, low energy, psychomotor changes, guilt, impaired concentration, suicidal ideation). This patient is at high risk for developing co-morbid major depression and should be monitored for worsening depressive symptoms. (Choice D) Although this patient exhibits some features of oppositional defiant disorder (angry/irritable mood, argumentative), this diagnosis requires >6 months duration of symptoms and is typically characterized by vindictive or deliberately annoying behavior. This patient's oppositional behaviors are better explained as manifestations of trauma. (Choice E) Substance abuse should always be considered as a cause of behavioral changes and academic decline. However, the type and extent of this patient's substance use are unlikely to explain the range and severity of her symptoms. Educational objective: Child abuse should be suspected in children and adolescents with sudden behavioral problems. Risky sexual behavior, in particular, may be an indicator of possible sexual abuse. References: Aspects of abuse: recognizing and responding to child maltreatment. (http://www.ncbi.nlm.nih.gov/pubmed/25771266) Childhood sexual abuse, sexual motives, and adolescent sexual risk-taking among males and females receiving child welfare services. (http://www.ncbi.nlm.nih.gov/pubmed/28139252)

A 14-Year-Old Girl Is Brought to the Clinic Due to Behavioral