A 5-year-old girl is brought to the physician because her mother has found her to be inattentive at home and has received multiple complaints from her teachers at school. She does not complete her assignments and does not listen to her teachers' instructions. She refuses to talk to her parents or peers. Her mother says, “She ignores everything I say to her!” She prefers playing alone, and her mother reports that she likes playing with 5 red toy cars, repeatedly arranging them in a straight line. She avoids eye contact with her mother and the physician throughout the visit. Physical and neurological examination shows no abnormalities. Which of the following is the most likely diagnosis?

Attention deficit hyperactivity disorder

A 3-year-old boy is brought in by his mother because she is concerned that he has been “acting differently recently”. She says he no longer seems interested in playing with his friends from preschool, and she has noticed that he has stopped making eye contact with others. In addition, she says he flaps his hands when excited or angry and only seems to enjoy playing with objects that he can place in rows or rigid patterns. Despite these behaviors, he is meeting his language goals for his age (single word use). The patient has no significant past medical history. He is at the 90th percentile for height and weight for his age. He is afebrile and his vital signs are within normal limits. A physical examination is unremarkable. Which of the following is the most likely diagnosis in this patient?

Pervasive developmental disorder, not otherwise specified

Childhood disintegrative disorder

A 9-year-old boy is brought to a pediatric psychologist by his mother because of poor academic performance. The patient’s mother mentions that his academic performance was excellent in kindergarten and first grade, but his second and third-grade teachers complain that he is extremely talkative, does not complete schoolwork, and frequently makes careless mistakes. They also complain that he frequently looks at other students or outside the window during the class and is often lost during the lessons. At home, he is very talkative and disorganized. When the pediatrician asks the boy his name, he replies promptly. He was born at full term by spontaneous vaginal delivery. He is up-to-date on all vaccinations and has met all developmental milestones on time. A recent IQ test scored him at 95. His physical examination is completely normal. When he is asked to read from an age-appropriate children’s book, he reads it fluently and correctly. Which of the following is the most likely diagnosis in this patient?

Attention-deficit/hyperactivity disorder

A 6-year-old boy presents to the pediatrician with his parents. He is fully vaccinated and met most developmental milestones. His fine motor milestones are delayed; at present, he cannot eat by himself and has difficulty in self-dressing. His intelligence quotient (IQ) is 65. He listens quietly while spoken to and engages in play with his classmates. He neither talks excessively nor remains mute, but engages in normal social conversation. There is no history of seizures and he is not on any long-term medical treatment. On his physical examination, his vital signs are stable. His height and weight are normal for his age and sex, but his occipitofrontal circumference is less than the 3rd percentile for his age and sex. His neurologic examination is also normal. Which of the following is the most likely diagnosis?

Attention deficit hyperactivity disorder

A 9-year-old girl is brought to the pediatrician for a wellness checkup. The girl's past medical history is non-contributory, and she has met all her developmental milestones. Her parents were recently called into the office as the girl was found touching the genitals of one of her classmates. She was trying to insert a toy into her classmate's genitals. The girl is asked what has happened and what she thinks is going on but she is too shy to reply to the physician. The girl and her mother recently moved in with a family member. They live in low-income housing subsidized by the government and are currently on food stamps. The mother states that her daughter has been particularly argumentative lately and that they have gotten into arguments in which her daughter screamed at her and locked herself in the bathroom. Which of the following is the most likely diagnosis?

Attention deficit hyperactivity disorder

A 4-year-old girl is brought to the pediatrician by her parents after her mother recently noticed that other girls of similar age talk much more than her daughter. Her mother reports that her language development has been abnormal and she was able to use only 5–6 words at the age of 2 years. Detailed history reveals that she has never used her index finger to indicate her interest in something. She does not enjoy going to birthday parties and does not play with other children in her neighborhood. The mother reports that her favorite “game” is to repetitively flex and extend the neck of a doll, which she always keeps with her. She is sensitive to loud sounds and starts screaming excessively when exposed to them. There is no history of delayed motor development, seizures, or any other major illness; perinatal history is normal. When she enters the doctor’s office, the doctor observes that she does not look at him. When he gently calls her by her name, she does not respond to him and continues to look at her doll. When the doctor asks her to look at a toy on his table by pointing a finger at the toy, she looks at neither his finger nor the toy. The doctor also notes that she keeps rocking her body while in the office. Which of the following is an epidemiological characteristic of the condition the girl is suffering from?

This condition is 4 times more common in boys than girls.

There has been a steady decline in prevalence in the United States over the last decade.

There is an increased risk if the mother smoked during pregnancy.

There is an increased risk with low prenatal maternal serum vitamin D level.

There is an increased incidence if the mother gives birth before 25 years of age.

A parent-teacher conference is called to discuss the behavior of a 9 year-old boy. According to the boy's teacher, he has become progressively more disruptive during class. When asked to help clean up or read out-loud, he replies with "You're not the boss of me." or "You can't make me." He refuses to participate in gym class, but will play the same games during recess. He gets along with and is well-liked by his peers. His mother reports that her son can "sometimes be difficult," but he is helpful around the house and is very good playing with his 7-year-old sister. What is the most likely diagnosis?

Antisocial personality disorder

A 29-year-old woman presents with convulsions. The patient’s brother says that he found her like that an hour ago and immediately called an ambulance. He also says that she has been extremely distraught and receiving supportive care from a social worker following a sexual assault by a coworker a few days ago. He says that the patient has no history of seizures. She has no significant past medical history and takes no medications. The patient’s vital signs include: temperature 37.0°C (98.6°F), pulse 101/min, blood pressure 135/99 mm Hg, and respiratory rate 25/min. On physical examination, the patient is rolling from side to side, arrhythmically thrashing around, and muttering strangely. Her eyes are closed, and there is resistance to opening them. Which of the following is the most likely diagnosis in this patient?

Functional neurological symptom disorder (Conversion disorder)

Somatic symptom disorder with predominant pain

Communication disorders for USMLE Step 2 CK: High-Yield Psychiatry Lessons

Communication Disorders - The First Word

Persistent difficulties in the acquisition & use of language across modalities (spoken, written, sign language).
Core types include Language, Speech Sound, Social (Pragmatic) Communication, & Childhood-Onset Fluency Disorder (Stuttering).
Onset is in the early developmental period.

⭐ Social (Pragmatic) Communication Disorder is distinguished from Autism Spectrum Disorder by the absence of restricted, repetitive patterns of behavior, interests, or activities.

Language & Speech Sound - Words Don't Come Easy

Language Disorder
- Persistent difficulty acquiring and using language across modalities (spoken, written, sign).
- Features: Reduced vocabulary, limited sentence structure, impaired discourse.
- Abilities are substantially and quantifiably below age expectations.
Speech Sound Disorder (SSD)
- A.k.a. Phonological Disorder.
- Difficulty with speech sound production causing ↓ speech intelligibility.
- Includes problems with articulation (e.g., lisp) and phonological processes.
Social (Pragmatic) Communication Disorder
- Primary difficulty in the social use of verbal and nonverbal communication.
- Deficits in context-appropriate communication, following conversational rules, and understanding nonliteral language.

⭐ Must differentiate from Autism Spectrum Disorder (ASD); Social Communication Disorder lacks the restricted, repetitive patterns of behavior, interests, or activities (RRBs) required for an ASD diagnosis.

Social Communication Disorder vs. Autism Traits

Childhood-Onset Fluency Disorder (Stuttering)
- Disturbance in normal fluency & time patterning of speech, inappropriate for age.
- Features: Sound/syllable repetitions, sound prolongations, broken words, audible/silent blocking, circumlocutions.
- Anxiety about speaking is common.
- Onset typically before age 6.
Social (Pragmatic) Communication Disorder
- Persistent difficulty in the social use of verbal & nonverbal communication.
- Deficits in:
  - Using communication for social purposes (e.g., greeting).
  - Changing communication to match context (e.g., classroom vs. playground).
  - Following rules for conversation & storytelling.
  - Understanding non-literal or ambiguous language (idioms, humor).

⭐ High-yield: Social (Pragmatic) Communication Disorder is distinguished from Autism Spectrum Disorder by the absence of restricted, repetitive patterns of behavior, interests, or activities (RRBs). If RRBs are present, diagnose ASD.

Differential Diagnosis - Autism or Awkward?

Autism Spectrum Disorder (ASD): Persistent deficits in social communication/interaction across multiple contexts, plus restricted, repetitive patterns of behavior, interests, or activities (RRBs).
Social (Pragmatic) Communication Disorder: Primary difficulty with the social use of language and communication. No RRBs are present.
Social Anxiety Disorder: Intense fear of being judged or scrutinized in social situations. Social skills may be present but are unused due to anxiety.

⭐ A history of restricted, repetitive behaviors (RRBs) is mandatory for an ASD diagnosis, clearly separating it from Social Communication Disorder.

High‑Yield Points - ⚡ Biggest Takeaways

Language Disorder involves persistent difficulties in the acquisition and use of language across modalities (spoken, written, sign language).

Speech Sound Disorder is characterized by difficulty with phoneme production and articulation, leading to unintelligible speech.

Childhood-Onset Fluency Disorder (Stuttering) presents with significant disturbances in normal speech fluency and time patterning.

Social (Pragmatic) Communication Disorder features primary deficits in the social use of communication, but without the restricted, repetitive behaviors seen in autism.

All disorders must manifest in the early developmental period and cause significant functional limitation.

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