NBME Behavioral Q

[MudPhud20XX]

A 20 month old boy is brought to the physician by his mother b/c she is concerned about his language development. His mother says, "I don't understand. His 4-yr old sister had no problems with speech when she was his age." He is able to make some sounds, including "b" and "p" spontaneously, but he seems slow to imitate words the parent say. He is active, able to run a few steps, and can recognize shapes and do simple puzzles. He is at the 60th percentile for length and weight, and 75th percentile for head circumference. He is friendly and cooperative and has good eye contact. Physical examination shows no abnormalities. Which of the following is the most appropriate initial statement by the physician?

A. I recommend that he undergo a hearing screening as soon as possible
B. I wouldn't worry. Boys often speak later than girls do
C. I'm going to schedule him for an MRI of the brain to exclude hydrocephalus
D. You should give him things only if he attempts to ask for them
E. You should have him evaluated by a child psychologist for possible autistic disorder.

So I am debating between A and E. I feel like I need to also make sure that he doesn't have any hearing impairment that could have prevented his language skills. Any thoughts? He clearly has problems with his language since at 20 months he should used more than 10 words. Is A less likely since the physical exam shows no abnormality?

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[SBR249]

I doubt the boy is autistic. The DSM definition for autistic spectrum disorders involve poor social interactions, restricted interests and behaviors, poor communication, etc. In this case, the boy seems well socialized. He makes eye contact, is friendly and sociable, and is cooperative. Absent any other symptoms, a speech problem wouldn't make me very suspicious for autism.

 

[MudPhud20XX]

I doubt the boy is autistic. The DSM definition for autistic spectrum disorders involve poor social interactions, restricted interests and behaviors, poor communication, etc. In this case, the boy seems well socialized. He makes eye contact, is friendly and sociable, and is cooperative. Absent any other symptoms, a speech problem wouldn't make me very suspicious for autism.

yeah that make sense. so what do you think the best answer is?

 

[Inderjeet]

I think E would be wrong, as any option that involves referring the patient is usually not correct. If its hydrocephalus, there should be other signs and symptoms, so it can be ruled out as well.

 

[thehundredthone]

Anyone ~2 years old with speech trouble gets a hearing assessment. Anyone normal gets it by age 4.

 

[DeeJay2728]

I hate Behavioral, so please excuse me... Why are we ruling out B?

 

[SBR249]

I have yet to see an early developmental milestones chart for the step that differentiates between male and female genders.

 

[MudPhud20XX]

I hate Behavioral, so please excuse me... Why are we ruling out B?

He clearly has problems with his language since at 20 months he should use more than 10 words.

 

[DeeJay2728]

I haven't seen any early developmental milestone charts for the step that differentiate between the male and female gender either, but many people seem to believe there are genetic differences as to why girls tend to speak earlier than boys do.

 

[animando]

A. I recommend that he undergo a hearing screening as soon as possible
B. I wouldn't worry. Boys often speak later than girls do. -> They may or may not, who cares, the only reasonable option is #1 because I DO worry.
C. I'm going to schedule him for an MRI of the brain to exclude hydrocephalus. -> Based on his growth parameters, he doesn't seem to have an abnormal big head.
D. You should give him things only if he attempts to ask for them. -> Bull****
E. You should have him evaluated by a child psychologist for possible autistic disorder. -> A friendly, cooperative little boy with good eye contact is probably NOT autistic.

Based on my limited ped knowledge, I'd say: with this little guy, I have 2 hypotheses.
*Maybe he is not very interested in speaking for now and that's not that bad, he'll catch up later.
*Or he has some hearing problem ("seems slow to imitate words the parent say" highly suggestive) and that's dramatic. At his stage of development, the brain should be sucking words and syllables like a sponge. If he's deaf and we don't fix the problem now, he might be irreversibly impaired in his communicative skills in the future. Another argument is the mother. If a mother says there is a problem with her child, rule out the problem.

 

[DeeJay2728]

I agree, and I'd want a hearing test asap if it were my child. But, bc there are so many grey areas in BS and "real life" vs "step" confusion, which is why I HATE THIS SUBJECT, I was asking if anyone can make it clear as to why B is ruled out, especially when there's so much support that rules it in... that's all.

 

[usmleswot]

I agree, and I'd want a hearing test asap if it were my child. But, bc there are so many grey areas in BS and "real life" vs "step" confusion, which is why I HATE THIS SUBJECT, I was asking if anyone can make it clear as to why B is ruled out, especially when there's so much support that rules it in... that's all.

I wrote B myself when I did the test and got it wrong but to put it most simply, First Aid says that by 2 years they should be speaking 200 words and making 2 word sentences, which it doesn't look like he is from the history. Behavioral Sciences is annoying, because there are just that many variables, and it often doesn't correlate with what you may do in practice. Just go into a behavioral question thinking "How can I be the world's most understanding and caring doctor in every possible way while all the while avoiding a law suit?". It worked for me. Hope this helps.

 

[Robotman]

A. I recommend that he undergo a hearing screening as soon as possible
B. I wouldn't worry. Boys often speak later than girls do. -> They may or may not, who cares, the only reasonable option is #1 because I DO worry.
C. I'm going to schedule him for an MRI of the brain to exclude hydrocephalus. -> Based on his growth parameters, he doesn't seem to have an abnormal big head.
D. You should give him things only if he attempts to ask for them. -> Bull****
E. You should have him evaluated by a child psychologist for possible autistic disorder. -> A friendly, cooperative little boy with good eye contact is probably NOT autistic.

Also for C. he has no motor defects, if the kid had hydrocephalus, the hydrocephalus would not discriminate and affect language centers but also motor centers.

Children try to mimic others when speaking, the b and p (also t) are common initial words of all children of any cultural background. If a child can't mimic his parents speech its because he has no ability to hear what the parents are saying.

 

[DeeJay2728]

I wrote B myself when I did the test and got it wrong but to put it most simply, First Aid says that by 2 years they should be speaking 200 words and making 2 word sentences, which it doesn't look like he is from the history. Behavioral Sciences is annoying, because there are just that many variables, and it often doesn't correlate with what you may do in practice. Just go into a behavioral question thinking "How can I be the world's most understanding and caring doctor in every possible way while all the while avoiding a law suit?". It worked for me. Hope this helps.

Thank you!! Very much appreciated!!!