-
[show abstract]
[hide abstract]
ABSTRACT: : Bryan is a 10-year-old boy who is brought to his pediatrician by his parents with concerns about oppositional behaviors. Bryan's parents report that he has always been hyperactive and oppositional since a very young age. He has been previously diagnosed with attention-deficit hyperactivity disorder and has been treated with appropriate stimulant medications for several years; however, despite this, his parents feel increasingly unable to manage his difficult behaviors. He refuses to do chores or follow through with household routines. He refuses to go to bed at night. His family feels unable to take him to public places because he "climbs all over everything." At school, he acts up in class, is often disruptive, and requires close supervision by teachers. He was recently kicked off of the school bus. He has very few friends, and his parents state that other children do not enjoy to be around him.Bryan's parents also report that he is "obsessed" with electronics. He spends most his free time watching TV and movies and playing computer games. He has a television in his bedroom because otherwise he "monopolizes" the family television. The family also owns several portable electronic devices that he frequently uses. Bryan insists on watching TV during meals and even that the TV stays on in an adjacent room while showering. He gets up early each morning and turns on the television. He refuses to leave the house unless he can take a portable screen device with him. His parents admit to difficulty placing limits on this behavior because they feel it is the only way to keep his other behaviors under control. His mother explains "it is our only pacifier" and that attempts to place restrictions are met with explosive tantrums and have thus been short lived. These efforts have also been impeded due to the habits of his parents and older sibling, who also enjoy spending a significant amount of time watching television.
Journal of developmental and behavioral pediatrics: JDBP 06/2013; 34(5):375-8. · 2.27 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Brian is an 11-year-old boy who presented to the emergency room with suicidal ideation and hearing voices. In the preceding weeks, he had escalating symptoms of oppositional defiant disorder, attention-deficit hyperactivity disorder (ADHD), and bipolar disorder. His medical history was notable for complex partial epilepsy with onset at age 4 that had been well controlled with divalproate. He had several mental health diagnoses by various practitioners including oppositional defiant disorder, ADHD, and bipolar disorder. Brian's family and social history was notable for the absence of identifiable risk factors for seizures or psychiatric problems. Over the course of a week-long psychiatric hospitalization, his complaints of depression and hearing voices seemed incongruent with his behavior. His parents endorsed a long history of Brian manipulating family and friends, such as conning his friends into stealing money and giving it to him. There was increasing suspicion that Brian was contriving his presenting symptoms for secondary gains. When his parents visited, he consistently bargained for prized items such as a long sought after cell phone and his own bedroom to improve his mood. His prior diagnoses (ADHD, a mood disorder, and oppositional defiant disorder) did not capture what seemed to be his core problem--an ability and willingness to manipulate others for his own self-serving purposes. Three months later, he was seen in the pediatric neurology clinic for increased seizure frequency. In the interim, he had several very serious altercations including setting fire to his family church, an attempted break-in-and-entry, assaulting his principal and resisting the arresting officer, and a malicious planned attack on his father where he struck him in the head with a crescent wrench "in cold blood, without any emotion."
Journal of developmental and behavioral pediatrics: JDBP 05/2012; 33(4):365-8. · 2.27 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: CASE:: Maria is a 9-year-old Latina girl who was followed up by her pediatrician since birth with normal developmental milestones, good school achievement, and without significant medical problems. She was not in the pediatric office for the past 3 years. At the age of 9 years, she presented for a health supervision visit. Her pediatrician looked at her growth chart-90 pounds (95th percentile) and height 52 inches (50th percentile)-that confirmed a clinical impression of obesity on physical examination. Her body mass index was 23.4 (>95th percentile for age).During 10 years in primary care pediatric practice, the pediatrician typically prescribed a management plan for obese school-aged and adolescent patients that started with parent and child education about potential health problems associated with obesity followed by a recommendation to decrease the caloric intake and encourage active exercise each day. She then arranged for follow-up visits to monitor weight and adherence to the management plan. However, a moment of self-refection suggested that most of her patients did not follow her advice in a sustained way. Obesity persisted in most cases. The pediatrician wondered if there was an alternative-better yet, evidence-based-approach to pediatric obesity that might provide a better outcome.
Journal of developmental and behavioral pediatrics: JDBP 11/2011; 32(9):688-91. · 2.27 Impact Factor
-
Mark Wolraich,
Lawrence Brown,
Ronald T Brown,
George DuPaul,
Marian Earls,
Heidi M Feldman,
Theodore G Ganiats,
Beth Kaplanek,
Bruce Meyer,
James Perrin,
Karen Pierce,
Michael Reiff, Martin T Stein,
Susanna Visser
[show abstract]
[hide abstract]
ABSTRACT: Attention-deficit/hyperactivity disorder (ADHD) is the most common neurobehavioral disorder of childhood and can profoundly affect the academic achievement, well-being, and social interactions of children; the American Academy of Pediatrics first published clinical recommendations for the diagnosis and evaluation of ADHD in children in 2000; recommendations for treatment followed in 2001.
PEDIATRICS 11/2011; 128(5):1007-22. · 4.47 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: CASE: Gerardo is an 8-year-old Latino boy who saw his primary care pediatrician with a second asthma exacerbation this year. His frustration with his illness was immediately apparent when he said, "I hate having to go to the nurse's office to take my albuterol!" His mother expressed concern that her son frequently refused to take his prevention medication for asthma, montelukast, each morning. When questioned about compliance with his inhaled steroid, his mother hesitated and then admitted that she discontinued the controller medication because she is afraid to "poison his body with so many chemicals." She consistently gave her son the inhaled steroid for 12 months, until care by the allergy specialist was unexpectedly transferred to a Spanish-speaking allergist. She complained that the new doctor is "cold and acts like a veterinarian, not a pediatrician." Gerardo is a first generation Mexican-American who was born in the United States to Spanish-speaking parents. There is no family history of asthma, although his mother fears that she may have contributed to Gerardo's condition. She explained that during pregnancy, she worked cleaning houses where she was exposed to many toxic household cleaners. She has always worried that by inhaling these fumes during pregnancy, she induced her son's asthma. Gerardo presented with his first episode of reactive airway disease at 9 months of age. His mother vividly recalled his high temperature, rapid breathing, and their ambulance ride to the hospital. He was hospitalized for 3 days, and he has not been hospitalized since. Allergy testing revealed sensitivity to weed pollen only. Gerardo sleeps with a nonallergenic pillow and bed cover. Gerardo's mother explained that 3 days before his current exacerbation, he was playing at an amusement park with his friends on a hot day. Gerardo and his friends ran through a large fountain. His mother reported that he was soaked in water and stated, "He knows that he will get sick with asthma if he gets wet!" She recalled that 3 years ago at a friend's birthday party, Gerardo abstained from running through the sprinklers with the other children without instruction from his parents. Since that event, she has trusted Gerardo to care for his "weak lungs." She is frustrated now with his regression in self-care.
Journal of developmental and behavioral pediatrics: JDBP 01/2011; 32(1):75-7. · 2.27 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: CASE: A 9-year-old girl was brought for consultation due to autism and a large head circumference. Her birth weight was 6 pounds after a 37-week gestation to a healthy G3P1SAb 2 mother. She had been a healthy child with the exception of the development of a lipomatous lesion on the left thigh, requiring surgical removal at age 3(1/2) years. Autism was diagnosed at age 5 yr by a developmental pediatrician. She did not have cognitive disabilities or a history of seizures. The family history was notable for maternal infertility with no history of developmental disabilities, large body or head size, or malignancy in close relatives.On physical examination, she was a mildly obese girl with a large head. Her weight was 50.4 kg (>95%), height was 142 cm (90%), and head circumference was 60.3 cm (significantly >95%; 4SDs above the mean). Examination of her skin was notable for a 2 x 6 cm scar on her left thigh and three café au lait macules on her trunk. She was Tanner Stage I. Mild hypotonia with normal deep tendon reflexes was observed; the remainder of the neurological examination was normal.Laboratory studies included high-resolution chromosomes, fragile X, metabolic screens, and methylation for Prader Willie Syndrome and Angelman Syndrome; all these studies were normal. Molecular testing of the PTEN gene (phosphatase and tensin homolog protein) revealed a R355X mutation, consistent with the diagnosis of Bannayan-Riley-Ruvalcaba Syndrome (BRRS). In parents and siblings, PTEN test results were negative for mutations.Endocrine evaluation revealed an abnormal thyroid nodule on ultrasound. Computed tomography and positron emission tomography scans raised suspicion of malignancy. She underwent a total thyroidectomy; the pathology report revealed a thyroid adenoma with Hurthle cells. She was treated with thyroid hormone replacement therapy.
Journal of developmental and behavioral pediatrics: JDBP 09/2010; 31(7):632-4. · 2.27 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: CASE: Derrick's parents made an appointment with a new pediatrician for a second opinion about disordered sleep. Now 22-months old, he was evaluated at 18 months of age for developmental delay when he was found to have "a regulatory disorder associated with delays in language and motor development, hypotonia and significant sleep problems." The parents are now most concerned about his sleeping pattern. Prolonged sleep onset and frequent night awaking occur each night since 6-months of age. These problems are more severe in the past few months when he awakes screaming and cannot be settled. The awakening episodes occur 2 to 4 times each night when "he screams and thrashes his body for up to an hour." Daytime tantrums increased. After the parents read a book about sleep in young children, they provided a calm atmosphere at bedtime including a dark room and singing a quiet lullaby. When these changes did not alter sleep, they purchased a vibrating mattress which was also unsuccessful. Derrick was born full term after an uncomplicated prenatal and perinatal course. He sat at 10 months, crawled at 12 months, and walked at 18 months. He currently drinks from a sippy cup and he can use a utensil to eat. He has few words saying only "no" and "mama" in the past month. Imitation of some words occurred recently. He has responded to simple directions in the past 2 months. Derrick passed the newborn audiology screen. He does not have difficulty swallowing and he does not drool. He plays with many different toys and he plays in parallel with his older brother who also experienced delays in motor and language development. His brother is now doing very well in school. There is no family history of cognitive delay, seizure disorder, cerebral palsy, early developmental delay (other than the brother) or a significant sleep problem.P hysical examination: head circumference, length and weight (75th percentile). He had mild generalized hypotonia, mild weakness, 2+ symmetrical deep tendon reflexes, and absence of ankle clonus. His gait was slightly wide based, steady, and without a limp. Neither ataxia nor drooling was observed. He was easily engaged in play with the examiner without evidence of irritability. The remainder of the examination was normal.
Journal of developmental and behavioral pediatrics: JDBP 05/2010; 31(4):357-9. · 2.27 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: CASE: Scott, a 13-year 7-month old white male with no prior psychiatric history, presented to the emergency department after three days of decreased attention span and increased distractibility. An initial examination revealed that he was internally preoccupied (focused on responding to auditory hallucinations), displayed thought blocking (sudden interruption in the flow of his thoughts that prevented him from completing an idea), and he had periodic vague suicidal ideation due to intense guilt. He noted hearing two to three voices accusing him of being rude during an incident with a peer at school. He could not accept reassurance from his mother and grandparents that this incident had not actually occurred. Scott found evidence of his wrongdoing by misinterpreting words on signs and medical equipment that he felt indicated that others also knew of his malicious actions. A recent stressor included the conclusion of his active football season a day prior to the onset of his symptoms. Scott and his family denied a history of prodromal symptoms, mental or medical illnesses, including head injury. After a physical/neurological examination, a negative urine drug screen, and a normal complete blood count and metabolic panel, Scott was transferred to a psychiatric hospital. Scott returned to the emergency department two days later with worsening psychotic symptoms despite a trial of olanzapine. He had deteriorated dramatically from his initial presentation. He was now rigid, unable to speak, move his body, follow directions, eat, drink, or provide any additional history. After being admitted to the pediatrics floor an extensive medical workup was completed that included neurology and infectious disease consults, brain magnetic resonance imaging and angiography studies, a 24-hour electroencephalogram, lumbar puncture, urinalysis, complete blood count, comprehensive metabolic panel, ceruloplasm, anti-nuclear antibody, anti-DNAase, erythrocyte sedimentation rate, heavy metal screen, ammonia, rapid plasma reagin (RPR), and human immunodeficiency virus. All laboratory studies were normal.
Journal of developmental and behavioral pediatrics: JDBP 04/2010; 31(3 Suppl):S103-6. · 2.27 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: CASE: Max is a 3-year-old healthy boy who was brought to the pediatrician's office by his mother for frequent temper tantrums at home. His teachers at the Montessori school are concerned about his communication skills. He is very talkative with his peers, but he constantly speaks about Thomas the Tank Engine. His peers seem to be uninterested in his repetitive stories. His teachers believe that Max has difficulty separating fantasy and reality. At home, his mother describes Max as "difficult to control." When placed in time-out, he hits, kicks and scratches his mother. He has a large vocabulary, but mostly speaks in phrases directly from cartoons. For example, he repeats a particular phrase from a program in which the main character grows in size with fury every time he gets angry and says, "I hate it, leave me alone." Before this exposure, the mother reports that her son had never used the word "hate." Max watches 5 hours of children's programs on television every day; he is not exposed to any news programs. Frequently, he watches the same episode of a program many times. Max's mother believes that he can watch as much TV as he wants as long as it is "good programming," so he only watches PBS kids shows and the Disney channel.
Journal of developmental and behavioral pediatrics: JDBP 04/2010; 31(3 Suppl):S107-11. · 2.27 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: CASE: Erica is a 13-year old female who was hospitalized for a 4-week history of "barking" noises and 2 weeks of generalized shaking episodes. Four weeks prior to admission, she had a viral upper respiratory infection (URI) with cough which was treated with over-the-counter cough syrup. After resolution of the URI, she developed a persistent cough that turned into a "bark"-like vocalization. Both the mother and patient demonstrated the bark as an "arf" sound like that of a small dog at times, a large dog at others. These vocalizations were unrelenting, occurring 3-10 times per minute only while awake. They were not precipitated by any known factors nor were there alleviating factors. She could not voluntarily suppress the sound. In addition to the vocalizations, episodes of generalized shaking of the extremities began 2 weeks prior to admission. According to Erica's mother, each episode lasted about 10-60 seconds and occurred 30-40 times a day only when she was awake. These episodes were not rhythmic or symmetric, and they were not associated with bowel or bladder incontinence. There was no alteration of consciousness following the episodes. Erica denied any recollection of the barking or shaking. The medical evaluation did not reveal an etiology. It included a complete physical examination, a neurological examination, biochemical laboratory studies, and a negative video EEG study that captured 10 episodes of shaking. Child psychiatry was consulted. Erica was a pleasant, quiet female with slightly constricted affect and a normal speech pattern. She reported that she was a straight-A honors student who had difficulty trusting others; she said that she had no friends, only "associates." She said that she had periods of feeling "sad" and crying easily, but could not identify any recent stressful event. Episodes of barking and shaking diminished during the hospitalization. Erica was discharged home with outpatient psychiatric follow-up.
Journal of developmental and behavioral pediatrics: JDBP 04/2010; 31(3 Suppl):S11-3. · 2.27 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: CASE: Maggie and Lily are 11 month-old twins who are brought by their parents to the Developmental-Behavioral Pediatric Clinic for a life-long history of feeding difficulties. The twins are this couple's first children. Their mother is tearful as she recounts a stressful pregnancy complicated by pre-term labor beginning at 24 weeks gestation with strict bed rest for the remainder of the pregnancy. The twins were delivered at 35 weeks gestation by Caesarian Section. Lily weighed 5 lbs 11 oz; Maggie was small-for-gestational age with a birth weight of 3 lbs 13 oz. Maggie required oxygen with nasal prongs for only a few hours after birth. She remained in the Neonatal Intensive Care Unit (NICU) with initial nasogastric tube feeding; she was advanced to bottle feeding prior to discharge. Both Maggie and Lily were slow to initiate and sustain formula feeding. They required over 1 hour to consume 2 ounces of formula and "tire easily". At 1 month of age, Maggie resisted feedings by crying and arching her back. By 5 months of age, both children cried at the sight of the bottle and tried to push it away. However, they never lost weight. Maggie was treated with intermittent naso-gastric tube feeding at 5-6 months of age in order to gain adequate weight. At 11 months of age, both girls continued to resist feeding, but their mother was able to "get in" 24 ounces each day of a 31-calorie/ounce formula "with a lot of work". Dad observed that his wife's entire day revolved around getting the twins to eat and that became a significant stress for her as well as on their relationship. The children had a gastroenterology evaluation including an upper gastrointestinal series, pH probe and gastro-duodenal endoscopy with biopsies. All studies were normal. Trials of omeprazole, metoclopramide and thickened feeds did not improve their feeding problem. They are currently not on any medications. They have not had a history of vomiting, diarrhea, or diaphoresis with feeds, and they have experienced only 1 mild upper respiratory infection. One or two soft bowel movements occur each day. Developmentally, they are on track for their age. The parents report that they can pull up to a stand and cruise, use a pincer grasps, and speak "mama" discriminately. A review of their growth charts reveal that their weight is consistently between the 10-25% percentiles; weight is currently at the 25% percentile. Head circumference and height are between the 25-50% percentiles.
Journal of developmental and behavioral pediatrics: JDBP 04/2010; 31(3 Suppl):S112-6. · 2.27 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: CASE: Carlos is a 12-year old Latino male who lives with his parents and his 5-year old sister. Carlos' mother is HIV positive. He was one year of age when his brother died of AIDS at the age of 3 years. Carlos' mother, who was severely depressed after his brother's death and continues to have episodes of depression, never informed Carlos about her HIV status. Carlos is HIV negative as determined by negative tests at birth and 18 months of age. Carlos developed numerous behavior problems in the past year. He was referred to the Children's Art Therapy Group sponsored by the University of California San Diego (UCSD) Mother, Child and Adolescent Program. The group is attended by HIV infected and affected children. Carlos did not understand why he was attending the group and asked his mother who was HIV positive. The mother eventually disclosed to Carlos that she was HIV positive. Subsequently, he was quiet, withdrawn and expressed anger in the art therapy group. His teacher, who was concerned about ADHD behaviors and academic underachievement in the past, reported that inattentiveness, poor concentration and forgetfulness were increasing in the classroom and his grades were falling. Carlos was referred to his pediatrician for an evaluation for ADHD. During the initial primary care appointment, a pediatric resident made a significant and positive impression on Carlos. The resident detected an underlying anger, and Carlos started to talk about himself and his family. The pediatric resident diagnosed ADHD, initiated medication, recommended classroom accommodations, and made a referral for individual therapy. Carlos continued to see the resident during monthly visits for monitoring ADHD treatment while encouraging Carlos to talk about home life, school and friendships.
Journal of developmental and behavioral pediatrics: JDBP 04/2010; 31(3 Suppl):S117-20. · 2.27 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: CASE: Dr. McClintock reviewed her schedule for the following week when she observed there were eight health supervision visits in 9 month old children. She recalled that these healthy children, whom she followed since birth, were up-to-date on their immunizations. As she reflected on the visits, it occurred to Dr. McClintock that this might be an ideal opportunity to use the time to assess developmental status and behavioral interactions. She could also ask questions about the families, including childcare arrangements, satisfaction with parenting and marriage relationships. Dr. McClintock considered the best use of the time available in order to have the most meaning to the children and their families. What lines of questioning or what screening tests might be most useful during the 9-month office visit?
Journal of developmental and behavioral pediatrics: JDBP 04/2010; 31(3 Suppl):S121-5. · 2.27 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: CASE: Sonia's mother was concerned about her 9-year old daughter's aggression, defiant behavior, and distractibility. When she was 4-years, she kicked her bother and he lost a tooth as a result of the trauma. At this time, her pediatrician was concerned about hyperactivity, impulsivity, and defiance of authority and recommended a psychological evaluation. Sonia's father refused an evaluation and responded by physically abusing his wife while demanding a transfer to a new physician. Sonia's mother left her husband at this time and moved away with Sonia. Spousal abuse occurred frequently before the separation, and Sonia may have been physically abused as well. Currently, Sonia is in third grade where she is underperforming in many areas. She enjoys drawing and reading, but struggles to sit quietly and stay on task. Her teacher reports frequent vocal and physical disruptions. Homework takes an inordinate amount of time to complete. She does not have a sustained friendship; her mother feels that this is because other kids do not like being bossed by Sonia. Her mother is concerned about Sonia's behavior especially the unremorseful disruptive behavior toward her younger brother and grandmother. Sonia was born after an uneventful full-term pregnancy without evidence of maternal smoking, drugs, alcohol, or medications. Motor and social developmental milestones were achieved at the appropriate time. Language milestones were achieved early; her mother recalls that Sonia learned to read at the age of 3 years. Sonia's medical history is significant for obesity, seasonal allergic rhinitis, and delayed sleep onset with prolonged awakenings associated with nightmares. Her mother reports that Sonia "worries about everything," including thoughts that her brother will turn into a monster. When an argument occurs at home, she "gets scared," bites her nails, and cries. Sonia currently lives with her mother, 2 younger brothers, step-father, and grandparents. Family history is significant for drug abuse by her father and mental illness in the father's family. While conducting an interview with her mother, Sonia was asked to draw a picture of her family. Instead, she illustrated a book detailing her past experience in words accompanying each drawing. She described how she watched her father physically abuse her mother and her persistent fear of danger when conflict occurred at home. Although spelling was poor, her vocabulary, sequencing, and illustrations demonstrated above age-level skills for written expression and drawing. Examples of the writing that accompanied the drawings include: "I hate when my parents fight. I get scared and feel sick to my tummy like I want to throw up. I just hate that feeling!" "My mom told me she had a 'boyfriend.' These words were the most horrible I ever heard. Soon a nightmare began. Nightmares make me very, very scared."
Journal of developmental and behavioral pediatrics: JDBP 04/2010; 31(3 Suppl):S126-9. · 2.27 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: CASE 1: At 3 years of age, Billy was seen by his pediatrician for a well child visit. Spontaneous speech was limited during the visit. He did not interact with the pediatrician and attempts to play with Billy resulted in oppositional behavior. About 3 months after the visit, Billy's parents requested a developmental evaluation; he was diagnosed with autism by means of an observational measure and a parent interview. Billy was born full term after an uncomplicated labor, delivery and postnatal period. Motor milestones were normal. His parents recalled that he used his finger to point to an object prior to using words. He spoke several single words by his first birthday and used phrases before age 2 years. Billy was described as often having difficulty with transitions, but he is happy and outgoing in familiar situations. At 3 years old, when he started preschool, Billy did not speak to either the teacher or other children. This pattern of refusal to speak persists. His parents report that he talks to them and one uncle using complete sentences with clear speech. Billy prefers to repeat activities and is reluctant to try activities. He frequently plays with the same toy cars placing them in a neat line and becomes upset if things are not done in the same way. An uncle has Asperger syndrome. CASE 2: Juan, a 3 year old Mexican-American boy, was referred by his preschool teacher because "he does not interact with other children or use language at an age-appropriate level." He prefers to play alone, resists participation in group activities at preschool, and does not share as well as other students according to his teacher. Expressive language with speech is rarely seen in preschool. In contrast, at home he plays interactively, shares toys with his older brother and speaks in short, clear sentences. In preschool, English is spoken exclusively. At home, Spanish is the primary language. Prenatal and birth histories were uneventful. Motor and social milestones were achieved art the expected times. He spoke his first word at 18 months and 2-word phrases at 2 years. Currently, he speaks in full sentences with pleurals and pronouns. He follows commands and recently had a normal audiogram. His parents, who speak English with ease, are concerned about the teacher's observations at school. The physical examination was normal; the developmental and behavioral assessments were conducted by an English speaking clinician. Juan played interactively with toys while demonstrating curiosity, showing and joint attention. There was no speech production during a 30 minute period although he did follow directions. When a Spanish speaking clinician assumed responsibility for the assessment, Juan's speech production increased significantly. He told a story about his drawing and talked about the family dog and his brother. He had good eye contact and appropriate pragmatic speech when the dialogue was in Spanish.
Journal of developmental and behavioral pediatrics: JDBP 04/2010; 31(3 Suppl):S14-7. · 2.27 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: CASE: John, a 14-year old white male of European Jewish descent without a prior history of medical or psychiatric problems, presented following several days of increased need for sleep (16-20 hours per day), disorientation, difficulty maintaining attention and concentration, bizarre behaviors. He was sexually inappropriate toward his mother, sister, and housekeeper, masturbated in public, and sang nonsense lyrics. In addition, he had brief periods of agitation, paranoia (including fear that he was being followed and that he would be hurt by the physicians), and periods of distraction by auditory and visual hallucinations. His appetite increased significantly during this time. One week prior to the onset of these symptoms, he traveled to the Midwest where he experienced several days of nausea, vomiting, and diarrhea. John's physical and neurological examinations were normal except for the behaviors noted above. A medical evaluation revealed a normal brain computerized tomogram (CT) and magnetic resonance imaging (MRI). Urine toxicology screen, a comprehensive metabolic blood panel, and a complete blood count were normal. A lumbar puncture demonstrated a slightly elevated opening pressure (24 centimeters); the cerebrospinal fluid examination was unremarkable for cells, protein and glucose. Following the lumbar puncture, for which he had received midazolam, he had a brief, 30-45 minute episode of lucidity in which he was able to describe feeling like he was "in a fog." John was transferred to a psychiatric hospital where he recovered over several days and was discharged home. After three weeks of complete recovery, he acutely developed profound fatigue and the previously seen bizarre behaviors returned and persisted for 2 weeks. Following a 2-week period without symptoms, a similar behavior pattern recurred for the third time. The third episode differed from the first two in that he initially developed mental status changes and then developed symptoms of hypersomnolence. John has now been completely recovered from the third two week episode for one week and is taking summer school classes and enjoying socializing with his friends.
Journal of developmental and behavioral pediatrics: JDBP 04/2010; 31(3 Suppl):S18-20. · 2.27 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: CASE: Tony is an 11-year old boy in the fifth grade whose mother describes him as "really a good kid who is bright and tries to be friendly. But he's always doing things that get him in trouble at school and sometimes at home." Tony was diagnosed with ADHD (combined type) 2 years ago. Stimulant therapy improved his attention and concentration during school, decreased hyperactivity in the classroom and improved educational achievements. However, Tony is oppositional and disruptive on the playground, during team sports and at home. His teacher observed that he wants to fit in, but he quickly gets in arguments with other children. He has difficulty sustaining friendships because he typically annoys others with unreasonable demands. He often has temper tantrums when things do not go his way; the tantrums are not prolonged but frequent. At home, on several occasions Tony hit his younger sister, and he once threw a dinner plate against the wall during a family meal. Although his mother describes these behaviors as present for many years, they seem to be escalating. Tony lives with both parents and his younger sister. There is no history of marital discord or major life event change in the past year. Standardized achievement tests demonstrate average to above average achievement scores. He continues to get mostly B grades and an occasional C. Tony's parents have tried to limit television time as a punishment for disruptive behaviors without any apparent effect. His mother reports that she yelled at him on several occasions when he refused to carry out household chores. "He gets angry at the simplest request for help." After meeting with Tony and his mother and completing a normal physical examination, the pediatrician referred Tony to a child psychologist for behavioral therapy.
Journal of developmental and behavioral pediatrics: JDBP 04/2010; 31(3 Suppl):S21-3. · 2.27 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: CASE: Tessa is a 7-year-old girl with odd behaviors, worsening over the preceding year. She spends a significant amount of time alone in her room, talking to "Richard." Her father observed that Tessa is "in her own world." In school, she often glares at the teacher and refuses to work. She is alone at recess without any real friends. Her father reports that she eats little and only after he tastes the food. She is increasingly cruel to both real and toy animals. She tied a string around her cat's neck and swung it around, saying she wanted to punish it. She was heard to say to her stuffed cat, "Die, b ... .; die." Richard told her to do this and other "bad" things. Tessa has not had chronic health problems or developmental concerns. During the first 18 months of life, her height was between the 5th and 10th percentiles; it declined to below the 3rd percentile over the past 2 years. Weight has been consistently between the 3rd and 5th percentiles. Tessa's parents both have been diagnosed with schizophrenia. There are at least 7 first- and second-degree relatives with the same diagnosis. Both parents cared for Tessa for 4 years with a lot of support. Then, her father left the home, but he was in contact with her while managing his own illness. When the mother's illness and compliance worsened, Tessa was removed for neglect at 5 (1/2) years old. Two foster homes preceded Dad's award of sole custody 13 months ago. Mother's weekly visitations are quite upsetting to Tessa. Tessa is a verbal, solemn, small, well-dressed girl with no physical abnormalities. She talks with advanced vocabulary and syntax, with normal prosody and good conversational skills. She says Richard is a bad boy who gets her into trouble at school. She equivocates when asked if he is real or imagined or if others can see him. She says that she misses her mother.
Journal of developmental and behavioral pediatrics: JDBP 04/2010; 31(3 Suppl):S24-9. · 2.27 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: CASE: A 7(1/2)-year-old boy is brought to a new primary care pediatrician because his grandparents, who have legal custody, want a "fresh look" at his behavior. Ian's grandmother begins the history with the comment, "He started out kind of rough." He was exposed to methamphetamine and marijuana throughout gestation and his mother had bipolar disease and hypertension. A Cesarean section for failure to progress was followed by normal Apgar scores and an unremarkable neonatal course. Ian's parents physically fought during the first 6 months of his life; at that time, the parents separated and the grandparents assumed care. Ian was expelled from three preschools due to physical aggression directed at other children. He also found it difficult to separate from his grandmother. In first grade, Ian often ran out of the classroom and was verbally, and at one time, physically abuse to his teacher. When he was expelled from school, the grandparents decided to home school Ian. Ian learned to read about 100 words and his spelling improved. Currently, Ian is in the first grade in a class of 10 children with behavioral problems; Ian has his own aid to insure his safety while in school. His teacher reports frequent fidgety behavior, difficulty sitting in his seat or at circle time, and trouble focusing on learning tasks. While his grandparents describe Ian as a "sweet and happy" child at home, they are concerned with repetitive behaviors (e.g., frequent flushing of the toilet because he worried that it is broken and brushing his teeth over 10 times each day), fear of leaving the house, and insisting on order to certain things such as his toys and having a "meltdown" when they are not in order. Severe tantrums are limited to once each month. A receptive and expressive language disorder was diagnosed at 4-years old followed by speech therapy and a social skills-language group program. A few months before the current pediatric visit, Ian had psychoeducational testing: The Wechsler Intelligence Scale-IV revealed verbal intelligence quotient (IQ) of 75 and a performance IQ of 108 with a full scale score of 81. The Gilliam Autism Rating Scale-2 indicated a probability of autism with significant scores in stereotype behavior, communication, and social interactions. During the physical examination, he constantly moved while in chair and required frequent redirection and refocusing on many tasks. Eye contact was appropriate, but he often used words out of context with scripted references to videos at home. Foul language was used both randomly and directed to the examiner. After saying, "here comes the bitch," he apologized. Ian demonstrated appropriate joint attention and reciprocal play without over-focusing on a single toy. Growth measurements were at the 95th percentile. Physical and neurological examinations were normal with the exception of mild asymmetry of auricle size and slightly abducted auricles in association with mildly small palpebral fissures.
Journal of developmental and behavioral pediatrics: JDBP 04/2010; 31(3 Suppl):S3-6. · 2.27 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: CASE: Scott, an 11-year-old boy in the fifth grade, is brought to his pediatrician, Dr. Lewis, by his maternal grandparents with the principle concern that "he lies constantly." Scott lived with his maternal grandparents since he was 2 years old, and they have full custody. His mother and father had serious substance abuse problems. The grandparents provide a stable home for Scott and his 15-year-old sister. Scott has had no contact with his mother in more than 6 years and sees his father infrequently. During the last visit with his father, he was so inebriated that he was thrown out of the movie theatre and barely avoided several car accidents on the way home. He left the children at the curb of their home and made them promise that they would lie to their grandparents about the reasons for the early return. Scott was diagnosed with attention-deficit hyperactivity disorder (ADHD) in second grade. Methylphenidate (36 mg) provides improvement in attention and concentration. His grandfather describes Scott as highly unpredictable. When he is the "good Jake," he is eager to help, polite, and caring. When Scott gets behind in school or is avoiding his chores and assignments, he lies by saying that he got it all done, even though he knows his grandfather will discover the lie and punish him. When confronted with reports from school, Scott often lies and may develop more elaborate confabulatory stories. His grandfather admits that he becomes irate at these moments. He responds by removing Scott's privileges. When he planned to take Scott to see his favorite sport team in the playoffs, Scott was caught in a lie the day of his departure. His grandfather offered him a chance to fess up, pay a small price in extra chores, and save the trip. Scott stubbornly refused to admit that he lied and lost the trip. His grandfather worries that Scott has no "moral compass." He takes things that do not belong to him and violates household curfew rules. He has never been physically aggressive or has never stole items from a store. He takes his sister's CD player or his grandfather's cell phone even when he has been told not to. He will then lie that he did not take it. Even when it is pulled out of his backpack, he will say he did not put it in there. His grandfather is a businessman with high moral integrity. He loves his grandson and is eager to help him. He asks Dr. Lewis what they should do about Scott's persistent lying.
Journal of developmental and behavioral pediatrics: JDBP 04/2010; 31(3 Suppl):S30-3. · 2.27 Impact Factor
