WBR1130

Author	[[PageAuthor::A 40 years old woman comes to a pediatrician with her 6 year boy. They recently shifted from Houston to Boston. The boy was enrolled in a new school. In a recent teachers-parents meeting, a mother was surprised to learn that boy was keeping quiet in the class. He hardly talked to anybody in the class. He is very reserved with other kids in class. However, mother says that the boy is very social at home and enjoys leisure time with cousins. Which of the following is the next best step in management?]]
Exam Type	ExamType::USMLE Step 2 CK
Main Category
Sub Category
Prompt	[[Prompt::A 40 year old woman comes to a pediatrician with her 6 year boy. They recently shifted from Houston to Boston. The boy was enrolled in a new school. In a recent teacher-parents meeting, mother was surprised to learn that boy was keeping quiet in the class. He hardly talked to anybody in the class. He is very reserved with other kids in class. However, mother says that the boy is very social at home and enjoys leisure time with cousins. Which of the following is the next best step in management?]]
Answer A	AnswerA::Refer to behavioral pediatrician
Answer A Explanation	AnswerAExp::This is a case of selective mutism and does not need a behavioural intervention.
Answer B	AnswerB::Screen for learning disabilities
Answer B Explanation	[[AnswerBExp::This is a case of selective mutism. The presence of a learning disability is sometimes suspected by a child's parent long before problems are seen at school. However, the issues typically become visible when a child begins having difficulty at school. Difficulty learning to read is often one of the first signs that a learning disability is present. Learning disabilities are often identified by school psychologist, clinical psychologist, and neuropsychologist through a combination of intelligence testing, academic achievement testing, classroom performance, and social interaction and aptitude. Other areas of assessment may include perception, cognition, memory, attention, and language abilities. The resulting information is used to determine whether a child is achieving at his or her potential. The DSM-IV, and many school systems and government programs have defined learning disabilities on the basis of a discrepancy between IQ scores and achievement scores. Although the discrepancy model has dominated the school system for many years, there has been substantial criticism of this approach (eg, Aaron, 1995, Flanagan and Mascolo, 2005) among researchers. Recent research has provided little evidence that a discrepancy between formally-measured IQ and achievement is a clear indicator of LD (Fletcher, 2003). Furthermore, diagnosing on the basis of a discrepancy does not predict the effectiveness of treatment. Low academic achievers who do not have a discrepancy with IQ (ie their IQ scores are also low) appear to benefit from treatment just as much as low academic achievers who do have a discrepancy with IQ (ie their IQ scores are higher).]]
Answer C	AnswerC::Consider screening for social phobia
Answer C Explanation	[[AnswerCExp::For one to be socially phobic, exposure to the feared situation must provoke anxiety and the person must recognize this anxiety as irrational (although this may be absent in children). If another disorder is present, the social phobic fear is unrelated to it. For instance, if a person has a history of panic attacks, having a panic attack must not be the sufferer's fear. Sufferers are typically more self-conscious and self-attentive than others. As a result, social phobics tend to limit or remove themselves from situations where they may be subject to evaluation. Sufferers often recognize their fear is excessive or irrational, yet can't seem to break out of the cycle. As such, the diagnosis of social phobia is made only when the fear leads to avoiding occupational functions, social activities, or relationships with others.]]
Answer D	AnswerD::Consider screening for selective mutism
Answer D Explanation	[[AnswerDExp::Selective mutism is by definition characterized by the following: Consistent failure to speak in specific social situations (in which there is an expectation for speaking, e.g., at school) despite speaking in other situations. The disturbance interferes with educational or occupational achievement or with social communication. The duration of the disturbance is at least 1 month (not limited to the first month of school). The failure to speak is not due to a lack of knowledge of, or comfort with, the spoken language required in the social situation. The disturbance is not better accounted for by a communication disorder (e.g., stuttering) and does not occur exclusively during the course of a pervasive developmental disorder, schizophrenia, or other psychotic disorder. Shyness, social anxiety, fear of social embarrassment, and/or social isolation and withdrawal Difficulty maintaining eye contact Blank expression and reluctance to smile Stiff and awkward movements Difficulty expressing feelings, even to family members Tendency to worry more than most people of the same age Desire for routine and dislike of changes Sensitivity to noise and crowds.]]
Answer E	AnswerE::Take the child into your custody and report to child protective services.
Answer E Explanation	AnswerEExp::There is no history suggestive of child abuse.
Right Answer	RightAnswer::D
Explanation	[[Explanation::Selective mustism is suspected when the symptoms are restricted to a particular environment and child is otherwise normal. Educational Objective: Selective mustism is suspected when the symptoms are restricted to a particular environment and child is otherwise normal. References: http://www.wikidoc.org/index.php/Selective_mutism http://www.wikidoc.org/index.php/Learning_disabilities http://www.wikidoc.org/index.php/Social_phobia]]
Approved	Approved::No
Keyword	WBRKeyword::selective mutism
Linked Question	Linked::
Order in Linked Questions	LinkedOrder::