Pediatric Examination and Board Review (50 page)

CASE 28: AN 8-YEAR-OLD BOY WITH AUTISTIC BEHAVIORS THAT ARE DIFFICULT TO CONTROL

An 8-year-old boy named Joey presents to the office for behavior management problems. He is nonverbal and likes to screech and twirl. He is very active, loves to run on the playground, and rides a 2-wheel bike without training wheels on a safe bike path. He attends a special school and receives speech, occupational therapy, and behavioral management services. He can be redirected from prolonged twirling but likes to put assorted nonfood items in his mouth and suck his thumb. Joey’s parents come to you requesting suggestions for interventions that might help him behave more appropriately, slow down, and not be so active.

SELECT THE ONE BEST ANSWER

1.
Joey’s developmental diagnoses include all of the following except

(A) classical autism

(B) mental retardation

(C) pica

(D) CP

(E) all of the above

2.
Key medical issues to monitor in nonverbal children include all of the following except

(A) dental caries

(B) blood sugar

(C) sleep disorders

(D) lead levels

(E) nonaccidental injury

3.
Which of the following is/are true about thumb sucking?

(A) 80% of infants, 40% of preschoolers, and 10% of children older than 5 years of age suck their thumbs or fingers

(B) thumb sucking can be self-calming; it may occur when the child is tired, frustrated, hungry, or unhappy

(C) if thumb sucking occurs beyond age 4 years, there is increased risk of malocclusion

(D) positive reinforcement techniques (eg, treats, extra story time, stickers, and replacing thumb sucking with squeezing a foam ball) can help manage the behavior

(E) all of the above

4.
The mother states that Joey only sleeps 2 hours per night. Useful approaches include which of the following?

(A) melatonin and structured behavioral management of sleep hygiene

(B) structured sleep routines

(C) daytime naps

(D) long-term use of a benzodiazepine

(E) A and B

5.
Joey begins to watch wrestling after school. One day the principal calls because Joey has shoved a smaller first-grade girl in the cafeteria and she hit her chin on the edge of the table. The injury required sutures. Which of the following statements about TV is/are true?

(A) hundreds of studies have demonstrated a link between exposure to TV violence and aggressive behavior

(B) TV viewing increases the risk of obesity

(C) TV should not be used as an electronic babysitter

(D) children who are nonverbal and at a preschool mental age may not distinguish the consequences of aggression seen on TV

(E) all of the above

6.
One year previously, Joey’s grandfather, who used to take him for long walks after school with a dog and let him choose songs from a jukebox at the drugstore, died. His mother wonders if this is the reason for his nightmares and night terrors. All the following are true about night terrors except

(A) children with night terrors bolt upright from their sleep, are glassy eyed, and may have autonomic signs

(B) night terrors occur during an abrupt transition from stage 4 non–rapid eye movement (REM) sleep to REM sleep

(C) children are really awake during night terrors

(D) at the end of 5-20 minutes of night terrors, the child returns to sleep

(E) all of the above are correct statements

7.
All the following are true about nightmares except

(A) nightmares are upsetting dreams

(B) nightmares do not occur during REM sleep

(C) parents should empathize with the child’s fright

(D) parents should comfort the child and stay nearby while there is distress

(E) transitional objects may be helpful

8.
Joey continues to wake at night, strip naked, and smear stools on the walls. All of the following are helpful management strategies except

(A) enforcing a toileting regimen during the day

(B) severe punishment

(C) restraining Joey’s hands

(D) emergency behavioral consultation

(E) all of the above are helpful strategies

9.
Which of the following specific behavioral interventions may be helpful?

(A) applied positive behavioral analysis

(B) placement in foster care

(C) administration of enemas after school

(D) sleeping with Joey

(E) C and D

ANSWERS

1.
(D)
Joey has autistic spectrum disorder, moderate mental retardation, and pica.

2.
(B)
Children who are nonverbal and children with cognitive disabilities are at risk for elevated lead levels from pica and hand-to-mouth behaviors. Because he is not always cooperative and often acts like a younger child, Joey is at risk for dental caries, sleep disorders, and nonaccidental injuries.

3.
(E)
Eighty percent of infants suck their thumb. Among preschool children, thumb-sucking can be used for self-calming or when a child is frustrated, unhappy, hungry, or tired. After age 4 years, it is associated with malocclusion. Positive reinforcement is a key management technique.

4.
(E)
Management of Joey’s sleep requires establishing sleep hygiene as well as judicious use of medications with wide safety margins. These include melatonin, as well as a short-term trial of a benzodiazepine. Eliminating daytime naps and getting up at the same time every morning are also important.

5.
(E)
Increased aggression is seen in preschoolers, school-aged children, or teens exposed to TV violence. TV watching is associated with decreased physical activity and poor food choices. This results in obesity. TV should not be used as an electronic babysitter. Parental vigilance and proactive rulesetting are required in all ages.

6.
(C)
During night terrors, the child is in REM sleep and not actually awake. Children do not remember the events.

7.
(B)
Nightmares do occur during REM sleep.

8.
(B)
Time-ins and time-outs are more appropriate than punishment for decreasing negative behaviors. In applied behavioral analyses, very specific targets are chosen and then shaped through use of discrete trials using appropriate reinforcers.

9.
(A)
Management of challenging behaviors includes applied behavioral analysis, family supports, and emergency respite services.

S
UGGESTED
R
EADING

Coronna EB. Autism spectrum disorder. In: Augustyn M, Zuckerman B, Caronna EB, eds.
Development and Behavioral Pediatrics: A Handbook for Primary Care
. Philadelphia, PA: Lippincott Williams & Wilkins; 2011:134-138.

Howard B. Managing behavior in primary care. In: Augustyn M, Zuckerman B, Caronna EB, eds.
Development and Behavioral Pediatrics: A Handbook for Primary Care
. Philadelphia, PA: Lippincott Williams & Wilkins; 2011:71-76.

Mindell JA, Owens JA.
A Clinical Guide to Pediatric Sleep: Diagnosis and Management of Sleep Problems.
2nd ed. Philadelphia, PA: WB Saunders; 2009.

Towbin K, Mauk J, Batshaw ML. Pervasive developmental disorders. In: Batshaw ML, ed.
Children with Disabilities.
6th ed. Baltimore, MD: Paul H. Brookes; 2007.

CASE 29: A 4-YEAR-OLD WHO WAS BORN PREMATURELY

David is a 4
¹
/
₂
-year-old boy who attends a Head Start preschool where staff members have requested a comprehensive assessment because they are very concerned about delayed speech, clumsiness, and kindergarten readiness. Specifically, he has poorly articulated sentences and can only be understood by strangers 50% of the time. He is very clingy and very reluctant to interact with other children, preferring to be engaged by adults. When playing in the backyard, he trips frequently. His mother states that he knows his name, age, and colors. He has difficulty following verbal requests, remembering the alphabet, and counting past 10. He has difficulty with dressing, using a fork, and drawing pictures.