A 7-year-old boy is brought to the clinic by his parents who are concerned about his academic performance. They state that he is constantly in trouble for not paying attention in class and has received numerous detentions for being “off task.” The parents say he is generally well behaved at home, although he does sometimes take a long time to complete his homework assignments because he is very meticulous and checks his work multiple times to make sure it is correct. The patient is well-behaved in the exam room and sits in the corner coloring while the physician speaks with the parents. Occasionally, he stares into space for 8-10 seconds, making a slight smacking motion with his lips.
Which of the following is the most appropriate treatment for his underlying condition?
- A) Carbamazepine
- B) Clonidine
- C) Cognitive behavioral therapy
- D) Ethosuximide
- E) Methylphenidate
The vignette describes the classic findings of absence seizures which generally last <10 seconds, involve staring spells and can include rhythmic movements (such as smacking of the lips). Ethosuximide is the first line treatment for absence seizures. Valproic acid is another common treatment that is generally second line.
Answer A: Carbamazepine, is incorrect. Carbamazepine is a useful anti-epileptic but is not successful in treating absence seizures.
Answer B: Clonidine, is incorrect. Clonidine is an appropriate treatment for Tourette syndrome. Although the patient is exhibiting some tic-like movements, he does not meet the criteria for Tourette syndrome as he has no vocal tics.
Answer C: Cognitive behavioral therapy, is incorrect. Cognitive behavioral therapy is useful in treating obsessive-compulsive disorder (OCD); however, the patient spending "meticulous" time on his homework is not enough to suggest a diagnosis of OCD.
Answer E: Methylphenidate, is incorrect. Methylphenidate would be the appropriate treatment for attention deficit hyperactivity disorder (ADHD). Absence seizures and ADHD are often confused; however, this patient does not show any signs of hyperactivity and no other signs of inattention other than the "staring spells." Additionally, he is only experiencing difficulties in one setting (school) and would need to be experiencing problems in at least 2 settings to be diagnosed with ADHD.
Key Learning Point
Broca, or expressive aphasia, is caused by damage to the inferior frontal gyrus.