AssessmentsChildhood and early-onset psychological disorders: Pathology review
USMLE® Step 1 style questions USMLE
A 3-year-old boy is brought to the pediatrician by his parent in winter for a routine checkup. He has missed several previous appointments since the parent was overwhelmed with work and could not take time off. According to the parent, the patient does not interact with other children in the neighborhood and often avoids eye contact with other people. Vitals are within normal limits. Height and weight are below the 10th percentile. The child is not wearing a jacket despite the cold weather outside. He makes minimal eye contact with the physician. Physical examination reveals patches of hair loss on the patient’s head. Oral examination reveals multiple dental caries. The remainder of the physical examination is noncontributory. The physician decides to interview the child separately. Which of the following diagnoses is the physician most likely concerned for?
Content Reviewers:Antonella Melani, MD
A 16 year old female, named Tayla, comes to the clinic because she’s been feeling urges to repeatedly blink her eyes, shake her head from side to side, or clear her throat. Tayla notes that she is able to suppress the urge for a while, but she eventually loses control of her actions. This all started a little over a year ago, and Tayla is under distress because her classmates often tease her about it. During the conversation, she suddenly utters an inappropriate curse word, and immediately goes on to say that she doesn’t know how that came out of her mouth. Physical examination reveals no neurological deficits and she shows normal cognitive skills for her age.
Okay, based on the initial presentation, Tayla seems to have some form of childhood or early-onset psychological disorder. These include several psychological conditions that typically have their onset during childhood, although some of these disorders may last into adulthood. As a consequence, these disorders can interfere with how the affected person functions independently in society, and impair everyday activities like working, studying, eating, and sleeping, as well as have an impact on their families.
For your exams, the most common childhood or early-onset psychological disorders are separation anxiety disorder, selective mutism, oppositional defiant disorder, conduct disorder, disruptive mood dysregulation disorder, tourette syndrome, and child abuse.
Let’s begin with separation anxiety disorder. That happens when separation from someone that the child is very attached to, like a parent, causes overwhelming or excessive fear and anxiety. In some cases, this can reach the point where it may lead to factitious physical complaints so that individuals can stay home and miss school. To be diagnosed as separation anxiety disorder, this needs to last for at least four weeks or more. Bear in mind, though, that this can be considered normal behavior until the age of 3 or 4.
Now, treatment includes cognitive behavioral therapy, or cbt for short, which is a type of talk therapy that primarily focuses on teaching the individual strategies to better cope with stress and social pressures, as well as identify the anxious patterns of thinking that might be influencing their disorder. Other approaches include play therapy, which uses play to help individuals deal with their anxiety, and family therapy, where parents and siblings can learn new ways to interact with the individual and help them when anxiety spikes.
Moving on to selective mutism, this is when individuals fail to speak at specific social situations, such as at school. The problem typically starts before the age of 5, and lasts for at least one month. Another high yield fact is that selective mutism is often accompanied by social anxiety disorder or social phobia, which is characterized by excessive anxiety caused by social or performance situations like meeting groups of new people, going on dates, and job interviews, where people feel like they are under scrutiny or being judged.
What’s important to remember here is that these individuals speak normally in other, presumably more comfortable situations, such as at home, and the failure to speak isn’t due to a lack of teaching or a communication disorder. Treatment of selective mutism typically comprises cognitive behavioral therapy, as well as play and family therapy. In some cases, medications might be recommended, especially selective serotonin reuptake inhibitors or ssris like fluoxetine, paroxetine, sertraline, citalopram, escitalopram.
Next is oppositional defiant disorder, or ODD for short. This is marked by angry or irritable mood, like temper loss; as well as argumentative or defiant behavior, which is when individuals frequently argue with authority figures; and vindictiveness or spitefulness, where individuals may feel resentful or believe that others are to blame for their own behaviors and may want to seek revenge. In order to be diagnosed with oppositional defiant disorder, these moods and behavioral patterns must be ongoing for at least 6 months. Treatment mainly involves cognitive behavioral therapy to change the child’s mood or feelings and improve their behavior.
Next is conduct disorder, where individuals recurrently violate other people’s basic rights, and may mistreat or show aggression to people or animals, steal from others, destroy property, or disregard moral values and norms of society. For your test, remember that to meet the diagnosis, individuals must be under 18 years of age. So if they are over the age of 18, it is diagnosed as antisocial personality disorder. And that’s a high yield fact! Treatment once again involves cognitive behavioral therapy.
Moving on to disruptive mood dysregulation disorder, which usually has its onset before the age of 10, and is characterized by recurrent explosive outbursts of intense anger and violence, sometimes causing injury to themselves or others. These outbursts occur in response to any real or perceived provocation, and are almost always out of proportion to the situation. For your exams, remember that these outbursts occur three or more times a week for at least one year. A unique characteristic of disruptive mood dysregulation disorder is that even in-between outbursts, these children are constantly irritable or angry. Treatment generally focused on changing their violent behaviors through cognitive behavioral therapy, while some individuals may also benefit from medications, such as stimulants or antipsychotics.
Next is tourette syndrome, a disorder characterized by tics, which are involuntary, brief, purposeless, and stereotypical movements or vocalizations that occur over and over, and aren’t side effects of some other disorder or substance abuse. For your exams, keep in mind that to diagnose tourette syndrome, three criteria must be met. First, the individual should present with at least two motor tics, such as twitching of the nose, jumping or head banging, as well as one vocal tic, which tend to manifest as grunting, barking, or throat clearing, but may also involve words, phrases, or sentences.
Some individuals may also present with specific vocal tics like echolalia, which is repeating the words or phrases of others, palilalia, which is repeating one’s own words, and a high yield one is coprolalia, which is verbally expressing inappropriate obscenities or curse words. And that’s actually the most widely known symptom of tourette syndrome, and certainly the one examiners love the most! The second criterium is that the onset of symptoms must be before 18 years of age. And third, the individual should have the symptoms for over a year.
Another high yield fact is that tourette syndrome is often associated with other psychiatric conditions, such as attention deficit hyperactivity disorder or adhd and autism spectrum disorder, as well as obsessive compulsive disorder or ocd, which is a specific type of anxiety disorder characterized by obsessions or recurrent and unwanted thoughts that usually lead to compulsions, which are actions performed to try and reduce the anxiety.
Treatment of tourette syndrome involves cognitive behavioral therapy to help individuals identify triggering events or feelings that precede tics to prevent them. In addition, individuals who don’t respond to cognitive behavioral therapy or present with distressing tics can be treated with medications, including alpha-2 receptor agonists like clonidine and guanfacine, typical antipsychotics like haloperidol, and atypical antipsychotics like risperidone or olanzapine.
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