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Chapter 17. Psychiatry

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A mother brings her 2-year-old boy in for evaluation of speech delay. He had a normal birth history and had no developmental regressions. The child does not say any words yet but does seem to understand some simple commands. He prefers to play by himself and does not seem interested in his other two siblings. During the office visit, he is noted to make poor eye contact and to frequently flap his hands. Aside from his poor development and lack of interaction, his neurologic examination is unremarkable except for a mild diffuse hypotonia and toe-walking. Further history is most likely to reveal that the child

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(A) likes to play house and pretend that he is the father

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(B) uses rudimentary sign language to express his needs

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(C) has a robust appetite and normal bowel habits

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(D) holds his hands over his ears when the blender or vacuum is used

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(E) likes to draw pictures and then to show the pictures to his parents

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(D) The child in the vignette has an autism spectrum disorder (ASD). The child has communication delay and lack of social interaction. The hand flapping is consistent with a stereotyped behavior, one of the hallmarks of the autism spectrum disorders. Among the associated symptoms/syndromes in ASD's, abnormal sensory integration is marked by abnormal response to sensory input. Children may crave sensory input (for example, rubbing the body against a carpet) or have an aversion to sensory input (for example, holding the hands over the ears when there is a loud sound). Of note, sensory integration disorder can be diagnosed in the absence of an autism spectrum disorder.

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The other answer choices represent behaviors that would be out of character for the typical child with an ASD. It would be unlikely that he would play house and pretend to be the father as children with an ASD do not engage in imaginative play. Use of sign language would also be unlikely because the language deficits in ASDs are in essence communication problems; therefore, all forms of communication are impaired (including nonverbal communication). Children with ASDs are frequently picky eaters and suffer from a variety of bowel and gastrointestinal (GI) problems. Because of a lack of craving for social interactions, a child with an ASD would be unlikely to draw a picture and then show it to his parents. (Charman, 289–305; Neurodevelopmental Disorders; Rowland, 575–578; Schiffer, 504–536)

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Charman T and Baird G. Practitioner review: Diagnosis of autism spectrum disorder in 2- and 3-year old children. Journal of Child Psychology and Psychiatry. 2002;43(3):289–305.

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Neurodevelopmental Disorders. Diagnostic and Statistical Manual of Mental Disorders....

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