Clinical Scenario:
A 3-year-old boy is brought to the pediatric clinic because of frequent episodes of hitting, biting and throwing objects for the past 8 months. His parents report that these episodes are particularly frequent when he is unable to communicate what he wants. He speaks only a few single words and occasionally uses two-word phrases. He understands simple instructions and can identify familiar objects.
He has good eye contact, points to share his interests, enjoys interactive play with his parents and responds when called by name. There is no history of developmental regression.
Which of the following is the most likely explanation for his aggressive behaviour?
A. Autism spectrum disorder
B. Conduct disorder
C. Frustration related to language delay
D. Oppositional defiant disorder
E. Normal developmental aggression
Correct answer & Explanation:
Explanation
Correct answer: C. Frustration related to language delay
At 3 years, a child with markedly limited expressive language may have difficulty communicating needs, wishes and emotions. This communication difficulty can produce frustration, which may manifest as tantrums, hitting, biting and other aggressive behaviors.
The history that aggression occurs particularly when the child cannot communicate what he wants is the key clue.
Although autism spectrum disorder can present with language delay and behavioral difficulties, this child has good eye contact, joint attention, pointing, interactive play and response to name, with no developmental regression. These features make autism less likely in this particular scenario.
Conduct disorder and oppositional defiant disorder would not be diagnosed simply from aggression in a 3-year-old with significant communication difficulty. The underlying developmental problem should first be assessed.
A child of this age with this degree of speech delay should undergo formal developmental and language assessment, including hearing assessment, rather than having the aggression treated in isolation.
Reference
American Academy of Pediatrics. Identifying Infants and Young Children With Developmental Disorders in the Medical Home: An Algorithm for Developmental Surveillance and Screening. Pediatrics. 2006;118(1):405–420.
American Academy of Pediatrics. Language Delays in Young Children: How to Help Parents Help Their Children. Pediatrics in Review.
