Berkowitz’s – Section XII: New Morbidity

Autism Spectrum Disorders

Robin Steinberg-Epstein, MD
CASE STUDY
The mother of 18-month-old twin boys is concerned because one twin is not talking as much as his twin sibling. They are both very active. She feels that even though the child is quiet, he is very smart. He likes to figure out how things work. He seems very sensitive to sounds and covers his ears around loud noises. He loves music and even knows which CD his favorite song is on. He will play with his sibling but doesn’t seem interested in other children. In your office, both boys are very active. It is difficult to get an adequate examination because this child is screaming the whole time. While both children have stranger anxiety, the twin about whom the mother is concerned seems to have extreme stranger anxiety. He otherwise appears well.
Questions
1. What is autism spectrum disorder (ASD)?
2. How does ASD differ from language delay?
3. How do you evaluate a child for ASD?
4. Where can a clinician refer a patient with an ASD?
5. What types of treatment are available?
6. Should a child suspected of having an ASD receive further immunizations?

Attention-Deficit/Hyperactivity Disorder

Andrew J. Barnes, MD, MPH, and Iris Wagman Borowsky, MD, PhD
CASE STUDY
Cody, a 10-year-old boy, has visited a primary care clinic annually for well-child care, seeing different pediatricians each time. After failing all subjects during the first half of fourth grade, his teacher asks his mother to see if Cody’s doctor can do anything to help him at school. When the appointment is made, the clinic obtains standardized attention-deficit/hyperactivity disorder (ADHD)-specific behavioral rating scales from Cody’s parents and teachers. Prior to the visit, the pediatrician reviews these rating scales and Cody’s medical history. She discovers that at Cody’s 6-year well-child visit, a colleague documented, “Likely has ADHD, medication is indicated.” The medical records indicate that the family deferred starting stimulant medication and were told to follow up as needed. There is no further mention of ADHD. Cody also has a history of several urgent care and emergency department visits for minor unintentional injuries.
Questions
1. What are the primary symptoms of ADHD? What other conditions should be considered in the differential diagnosis of ADHD?
2. What other psychiatric disorders or neurodevelopmental disabilities commonly coexist with or mimic ADHD?
3. What is the appropriate evaluation of children with suspected ADHD?
4. What treatment modalities are useful in the management of ADHD?
5. What is the role of primary care in the long-term management of ADHD?

Psychopharmacology in Children

Robin Steinberg-Epstein, MD, and Kenneth W. Steinhoff, MD
CASE STUDY
An 8-year-old girl has been diagnosed with high-functioning autism spectrum disorder. The local developmental-behavioral pediatrician has recommended treating her anxiety and inattention with atomoxetine. The girl’s mom is very hesitant. She trusts you and wants your opinion.
Questions
1. How does one assess the safety and appropriateness of psychotropic medications?
2. What kind of blood tests are used to maximize safe administration and how often are they performed?
3. What is the evidence that psychotropic medications are overprescribed?
4. What are the usual side effects of commonly used psychotropic medications?

Physical Abuse

Melissa K. Egge, MD, and Sara T. Stewart, MD
CASE STUDY
A 6-month-old boy arrives at the emergency department after becoming limp and nonresponsive at home. The mother states that her son was fine when she left him in the care of her boyfriend before going to the store for cigarettes. When she returned 1 hour later, he was asleep, but then he seized and stopped breathing. The infant is being ventilated by bag-valve-mask ventilation. On
examination, the infant is pale and limp. His heart rate is 50 beats/min and blood pressure is 130/80 mm Hg. There are no external signs of injury.
Questions
1. What are the major lethal injuries associated with physical abuse of children?
2. What are the types of injuries seen in physically abused children?
3. What are the presenting signs in children with head injuries?
4. What are the legal obligations of physicians in the area of child abuse?

Sexual Abuse

Sara T. Stewart, MD
CASE STUDY
A 4-year-old girl is brought to the emergency department with the complaint of vaginal itching and discharge. Her past health has been good, and she has no medical problems.
She lives with her biological parents and her 2-yearold brother. On physical examination, the vital signs are normal and the child is well except that the genital area is swollen and erythematous and a green vaginal discharge is present. The girl is interviewed briefly but denies that anyone has touched her. The mother states that she has never left her daughter unattended and is angered by the questions.
Questions
1. What are the anogenital findings in prepubescent and postpubescent children who may have experienced sexual abuse?
2. What behavioral problems are common in children who have been sexually abused?
3. What are the pitfalls in disclosure interviews of children who have been sexually abused?
4. What is the significance of sexually transmitted infections in children who have been sexually abused?

Failure to Thrive

Carol D. Berkowitz, MD
CASE STUDY
A 2-year-old girl is brought to the office because of her small size. She was born at term but weighed only 2,200 g (,fifth percentile) and measured 43 cm (,fifth percentile). The mother is a 30-year-old gravida 5, para 4, aborta 1 who smoked during pregnancy but denies using alcohol or drugs. She received prenatal care for only 2 weeks prior to delivery, and she claims to have felt well. The child’s physical health has been good. She is reported to be normal developmentally but speaks only 4 to 5 single words. She has not yet started toilet training. The family history for medical problems, including allergies, diabetes, and cardiac and renal disease, is negative. The mother is 5 feet (152 cm) tall, and the father is 5 feet, 4 inches (163 cm) tall. The girl has 3 siblings, aged 5 years, 4 years, and 3 years, who are all normal. The father is no longer in the household. The mother is not employed outside of the home, and she receives public assistance. She states that frequently there is not enough food in the home, although she receives food stamps. On physical examination, the girl is below the fifth percentile in height and weight. Although she is very
active, she does not use any understandable words. The rest of the examination is normal.
Questions
1. What are the key prenatal factors that affect the growth of children?
2. How can caloric adequacy of a diet be assessed?
3. How do parental measurements affect their children’s stature?
4. What are the behavioral characteristics of infants
with environmental failure to thrive (FTT)? 5. What are some strategies to increase caloric intake of infants and children?
6. What, if any, laboratory studies should be routinely obtained when evaluating children for FTT?

Fetal Alcohol Syndrome

Melissa K. Egge, MD
CASE STUDY
A 6-year-old boy is brought into the clinic by his maternal aunt who expresses concerns about her nephew’s behavior that are echoed by his kindergarten teacher. The teacher has reported that the child has a limited attention span and is often disruptive in class. The child’s growth parameters have remained at the third percentile since birth. He has a smooth philtrum, thin upper lip, and short palpebral fissures.
Questions
1. What are the diagnostic criteria outlined by the Centers for Disease Control and Prevention for fetal alcohol syndrome (FAS)?
2. What is the differential diagnosis of the facial characteristics of FAS?
3. What typical behavioral and learning problems do children with FAS experience?
4. What therapeutic interventions are appropriate to recommend for children with FAS?

Newborns of Substance-Abusing Mothers

Sara T. Stewart, MD
CASE STUDY
A neonate is born by emergency cesarean delivery because of abruptio placentae. The mother is a 29-yearold gravida 6, para 4, aborta 2 with a history of crack cocaine and heroin abuse during pregnancy. The newborn is 36 weeks’ gestation with a birth weight of 2,400 g and length of 43 cm. Physical examination is normal. The newborn does well for the first 10 hours but then develops jitteriness with irritability, diarrhea, sweating, and poor feeding. A urine toxicology test on the newborn and mother are positive for cocaine.
Questions
1. What complications affect neonates secondary to maternal substance abuse during pregnancy?
2. What withdrawal symptoms do newborns experience as a result of maternal substance abuse during pregnancy?
3. What typical behavioral and learning problems are found in newborns, infants, and children whose mothers abused illicit substances during pregnancy?
4. What are the appropriate management strategies for neonates who have experienced in utero drug exposure?

Substance Abuse

Monica Sifuentes, MD
CASE STUDY
A 17-year-old male is brought to your office by his father with a chief complaint of chronic cough. You have followed this patient and his siblings for several years and know the family quite well. The father appears very concerned about “this cough that just won’t go away.” The adolescent is not concerned about the cough, however, and reports no associated symptoms such as fever, sore throat, chest pain, or sinus pain. You ask the father to step out of the room for the rest of the interview and the physical examination. On further questioning, the patient reports that he smokes a few cigarettes a day and has tried marijuana as well as cocaine. He denies regular use of these substances but reports exposure to these drugs at parties and when he hangs out with “certain friends.” The adolescent is now in the 11th grade, attends school regularly, and thinks school is “OK.” His grades are average to above average, but he thinks he might fail history this semester. Although he used to play baseball, he dropped out last year. He hopes to get a part-time job at a local fast-food restaurant this summer if his parents let him. Currently he is sexually active and uses condoms occasionally. He denies suicidal ideation and exposure to any firearms. On physical examination, he appears well developed and well nourished with an occasional dry cough. He is afebrile, and his respiratory rate, heart rate, and blood pressure are normal. Pertinent findings on examination include slight conjunctival injection bilaterally and mild erythema of the posterior pharynx. No tonsillar hypertrophy is apparent. The rest of the examination is within normal limits.
Questions
1. What are the most common manifestations of substance use and abuse in adolescents?
2. What are the risk factors associated with substance abuse in adolescents?
3. What other conditions must be considered when evaluating adolescents with a history of chronic substance abuse?
4. What laboratory evaluations, if any, should be considered in adolescents with suspected substance use or abuse?
5. What are the specific consequences, if any, of short-term and long-term use or abuse of substances such as alcohol, marijuana, cocaine, opiates, and hallucinogens?

Eating Disorders

Monica Sifuentes, MD
CASE STUDY
A 16-year-old female is brought to the office by her mother because she feels that her daughter is too thin and appears tired. The mother complains that her daughter does not eat much at dinner and always says she is not hungry. Recently, the girl bought diet pills that were advertised in a teen magazine. The teen claims that she hasn’t taken the pills, so she doesn’t understand why her mother is so upset. She says she feels fine and considers herself healthy because she has recently become a vegetarian. The girl is a 10th-grade student at a local public school and attends classes regularly, although her friends are occasionally truant. She is involved in the drill team, swim team, and student council. She has many friends who have “nicer” figures than she does. Neither she nor her friends smoke tobacco or use drugs, but they occasionally drink beer at parties. The girl is not sexually active and denies a history of abuse. Her menstrual periods are irregular; the last one was approximately 3 months ago. She currently lives with her mother, father, and 2 younger siblings. Although things are “OK” at home, she thinks her parents are too strict and don’t trust her. They have just begun to allow her to date, but she dislikes that she has a curfew. Her physical examination is significant for a thin physique and normal vital signs. On the growth chart, her weight is at the 15th percentile and her height at the 75th percentile, giving her a body mass index of 17 (10th percentile). The remainder of her physical examination is unremarkable.
Questions
1. What are the common characteristics of disordered eating in adolescents?
2. What are the important historical points to include when interviewing patients with suspected eating disorders? Which teens are considered at risk?
3. How is the diagnosis of anorexia nervosa (AN) and bulimia nervosa (BN) made?
4. What is the treatment plan for adolescents with eating disorders?
5. What are the medical complications of AN and BN?
6. What is the prognosis for these conditions? How can primary care practitioners help improve the outcome?

Body Modification: Tattooing and Body Piercing

Monica Sifuentes, MD
CASE STUDY
A 16-year-old girl comes to your office for her annual physical examination. Although previously healthy, the mother is concerned that her daughter seems irritable and unwilling to participate in recent family events. The adolescent is currently in 10th grade at a local public school, gets As and Bs in most subjects, is a member of the volleyball team, and has just begun working at a movie theater part-time. Both of her parents are employed and the adolescent gets along well with her 19-year-old sister, who is currently in college, and her 14-year-old brother. She has many friends in the neighborhood as well as at school. You interview the adolescent alone and learn that she occasionally smokes marijuana, has tried cocaine on one occasion, and attends parties where many people are drinking alcohol. She has been sexually active in the past but is not currently. She denies depression and describes her mood as generally happy, except when she is forced to spend what she believes is excessive time with her family instead of friends. On physical examination, the adolescent’s height and weight are in the 50th percentile for age. Her body mass index is 21. Vital signs are normal. You note a small tattoo at her right hip area. The girl’s mother is unaware of its presence, according to the teen. She obtained it a few months prior while visiting her sister in college.
Questions
1. What is the epidemiology of body modification in adolescents and young adults?
2. What is the motivation for obtaining tattoos and body piercing in this age group, and is there an association with high-risk behavior?
3. What techniques are used to place tattoos and perform body piercing?
4. What adverse consequences can be seen following body modification, and what should be done to treat them?
5. How can the primary care physician assist an adolescent to make a safe and healthy decision about body modification?

Childhood Obesity

H. Mollie Greves Grow, MD, MPH
CASE STUDY
A 10-year-old girl is brought to the office by her mother to discuss concerns about the child’s weight, which is 59 kg (130 lb). Her height is 140 cm (55 in), giving her a body mass index of 30 kg/m2 (.95th percentile for age). The rest of the physical examination, including vital signs, is normal. The mother, who also is overweight, says she doesn’t want her daughter to “end up like me.” The patient says she gets teased at school for being “fat.” The history reveals that this patient is an only child who lives with her single mother in low-income housing in a large urban city.
The mother works the day shift as a nurse’s aide at a nearby nursing home. Because the mother is often tired, meals are simple and frequently consist of prepackaged foods such as pastries for breakfast and frozen dinners for supper. At school, the girl buys her lunch, which usually includes whole milk, a processed entrée, and a dessert. After school, the girl goes home, where she watches television and snacks on chips and soda until her mother arrives home from work. The mother does not allow her daughter to play outside because the neighborhood is unsafe.
Questions
1. How is obesity defined and measured, and what are some pitfalls in measurement?
2. How do genetic susceptibility and environment interact to influence a person’s risk for obesity?
3. What are the complications of obesity?
4. What is the role of primary care physicians in addressing childhood obesity?
5. How can obesity be treated?

Divorce

Carol D. Berkowitz, MD
CASE STUDY
A 7-year-old girl who has been your patient for 5 years is brought in by her mother with abdominal pain that occurs on a daily basis and is not associated with any other symptoms. The pain is periumbilical. In obtaining the history, you learn that the father has moved out of the home and the parents are planning a divorce. The mother believes that her daughter’s symptoms may relate to the impending divorce, and she wants to know what else to expect.
Questions
1. What are the problems faced by children whose parents are undergoing divorce?
2. What are the age-related reactions of children in families undergoing divorce?
3. What are the custodial issues and arrangements following divorce?
4. What is the role of pediatricians in counseling families undergoing divorce?
5. What anticipatory guidance can be offered about custody and remarriage?
6. How can pediatricians help stepfamilies adjust?

School-Related Violence

Catherine A. DeRidder, MD
CASE STUDY
A mother brings in her 9-year-old son, Alex, complaining of recurrent abdominal pain. His pain has become so severe that Alex misses school frequently. He denies any vomiting or diarrhea. His weight has been stable over the last 6 months. Alex’s mother reports that lately he seems more withdrawn and passive. He used to be engaged in his schoolwork but now, with his frequent absences, has lost interest in school. His mother says he is often anxious or nervous about new situations.
Questions
1. How does school-related violence affect children’s health and well-being?
2. What is the relationship between bullying and adult criminal behavior?
3. What is cyberbullying?
4. What children are at risk for being bullied or for becoming a bully?
5. What can pediatricians do to help address violence in the school, home, and communities?

Intimate Partner Violence

Sara T. Stewart, MD
CASE STUDY
A 6-year-old boy is brought in by his mother for an annual well-child visit. He sits quietly as his mother reports no significant medical history. His medical records reflect that at his last visit he was talkative, doing well in school, and enjoyed playing baseball. As you speak with his mother, she seems reticent and does not spontaneously offer information. You determine that the boy’s school performance has declined significantly over the past year and that he no longer wants to play baseball. On physical examination, the boy has linear ecchymoses over his buttocks, and you notice bilateral areas of bruising on his mother’s upper arms. When you ask about the marks, she becomes tearful. You ask her if she would like to speak privately with you.
Questions
1. How often do child abuse and intimate partner violence (IPV) co-occur?
2. What are potential strategies to screen for IPV?
3. What are common clinical presentations of victims of IPV and children exposed to IPV?
4. What are the long-term consequences of IPV on children?
5. What are key factors to take into account when determining the degree and immediacy of danger to a victim of IPV?

Disaster Preparedness

Katherine E. Remick, MD, and Timothy K. Ruttan, MD
CASE STUDY
A family comes in for a well-child visit with their 9-month-old daughter, who has complex congenital heart disease, and their 7-year-old son. The mother is concerned after a recent tornado in the next town resulted in prolonged power outages and what the family might do in this situation. The daughter needs daily breathing treatments and often requires oxygen at nighttime. She is on multiple medications and a special formula. All of her specialty doctors are at the children’s hospital, which is more than an hour from their house. She is also concerned because her husband has a seizure disorder that requires medication. She asks whether the family should stay together in a disaster or separate to get her daughter to the children’s hospital.
Questions
1. How should families prepare for disasters, particularly natural ones known to occur in their area?
2. What should be included in disaster preparedness kits? How should medications for all family members be included?
3. When should families consider getting a generator?
4. How can families notify the utility company that they need to be flagged for priority return of service during a power outage?
5. What is the role of the local hospital and emergency medical services when families have children with special health care and critical medical needs?
6. What should the pediatrician recommend to families about children’s immunization records and important medical history?
7. How do you assess for the effect of traumatic events on children and their families?

Adolescent Depression and Suicide

Monica Sifuentes, MD, and Robin Steinberg-Epstein, MD
CASE STUDY
A 15-year-old girl is brought to your office by her mother with the chief complaint of easy fatigability. The mother is concerned because her daughter is always tired, although several other physicians have told her that the girl is healthy. The adolescent, who states no complaints or concerns, appears very shy. She is currently in the 10th grade, likes school, receives average grades, and speaks English and Spanish. The mother, a single parent, moved to the United States from El Salvador approximately 2 years ago with her 2 daughters. They are currently living with relatives
in a 2-bedroom apartment. The mother is employed as a housekeeper, and the patient and her sister help their mother clean homes on weekends. During the week they make dinner for the rest of the family as a means of contributing to the rent. When you speak to the girl alone, she acknowledges she has a few friends at school and adamantly denies any drug, alcohol, or tobacco use. She has never been sexually active and reports no history of sexual or physical abuse. The girl’s physical examination is entirely normal, although her affect appears somewhat flat.
Questions
1. What is the significance of nonspecific symptoms, such as fatigue, during adolescence?
2. What factors contribute to depression in adolescents?
3. What are the classic signs and symptoms of depression in adolescents?
4. What are some important historical points to cover when interviewing adolescents with suspected depression?
5. How is the risk of suicide assessed in adolescent patients?
6. How should suicidal behavior (ie, suicide attempts) be managed in adolescents?