Suzanna was born to a 26-year-old woman who used cocaine, alcohol, and cigarettes and experienced domestic violence throughout her pregnancy. Suzanna was placed in foster care with her current adoptive family after her birth. Her initial evaluation at 4 years revealed a global developmental delay (physical: 6 months; social and communication: 12 months). Improvements in development seemed to be in response to subsequent interventions. At 5 years, she had borderline intellectual functioning, an expressive or receptive language disorder, and attention-deficit hyperactivity disorder.
Suzanna experienced an abrupt developmental decline at 6 1/2 years old. She lost cognitive abilities, and she no longer carried on conversations. Although she was no longer interactive with most people, she remained affectionate with her parents. Her mother thought that Suzanna had visual and auditory hallucinations. In addition, she developed encopresis and hand flapping. A neurological evaluation, including a test for Rett Syndrome, was negative. Her Full Scale IQ dropped from 73 to 50 with decreased adaptive functioning and clinically significant problems with hyperactivity, attention, and functional communication.
Suzanna's development stabilized temporarily during an 18-month period. A second period of declining function included “zombie-like” behavior, anxiety, and hallucinations. Weekly sessions in child psychiatry included treatment with risperidone, methylphenidate, and supportive therapy for mother and child. After some clinical improvements in behavior, attention, and functioning, a psychological assessment confirmed the persistence of moderate mental retardation. A multidisciplinary team considered a diagnosis of childhood disintegrative disorder.
Regina Bussing, MD, Departments of Psychiatry, Pediatrics and Clinical and Health Psychology, College of Medicine and College of Public Health and Health Professions, Gainesville, FL.
Siraj Siddiqi, MD, Department of Pediatrics, College of Medicine, Gainesville, FL.
David M. Janicke, PhD, Department of Clinical and Health Psychology, College of Public Health and Health Professions, University of Florida, Gainesville, FL
Mary Jo Harbert, MD, Department of Pediatrics, University of California San Diego, CA
Doris Trauner, MD, Department of Pediatrics and Neuroscience, University of California San Diego, CA; and Rady Children's Hospital, San Diego, CA.
Martin T. Stein, MD, Professor of Pediatrics, Division of Child Development and Community Health, University of California San Diego, Rady Children's Hospital, San Diego, CA.
The case summary for the Challenging Case was posted on the Developmental & Behavioral Pediatrics web site http://dbpeds.org.list.