الأربعاء، 14 نوفمبر 2012

MCQs In Pediatric Pscychiatry

Q 1:


You are examining a healthy 3-year-old boy. His mother reports that he still sucks his thumb.
Of the following, the MOST appropriate management is:

A.   no treatment before 4 to 6 years of age
B.   orthodontic appliance
C.   physical barrier to thumb sucking, such as mittens
D.   psychological counseling
E.   topical aversive taste treatment applied to the thumb

Answer

A


Thumb sucking is a normal behavior in early infancy whose incidence peaks at 18 to 21 months of age. It is generally viewed as a biologic drive that develops into a habit. It typically resolves by 4 years of age, but it can persist much longer. Problems associated with thumb sucking depend on the habit’s duration, intensity, and frequency and can include malocclusion; paronychia; infection; digital hyperextension, soreness, and callous formation; accidental poisoning; and psychosocial issues. Many parents do not approve of the behavior and some will criticize, ridicule, or punish thumb suckers. Children who suck their thumbs often are viewed as less fun, happy, likable, attractive, intelligent, and desirable as friends or classmates.

            Thumb sucking treatment may be considered when any of the problems listed previously affect the child’s physical or psychosocial well-being. Treatment is not considered necessary before 4 to 6 years of age. Options include orthodontic appliances, physical barriers, aversive taste treatments, and when appropriate, psychological counseling. Orthodontic appliances, although effective, are very expensive. Physical barriers, such as mittens or socks, have variable rates of success. Topical aversive therapies may work, but only with the child’s approval. Thumb sucking and other chronic habits may be markers for anxiety or stress that might require an evaluation of the child’s and family’s psychosocial functioning. Most thumb sucking in childhood is harmless and self-limited and does not require directed intervention.


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Q 2 :


A 2-year-old girl began banging her head on her crib side rails at age 10 months and continues to do so most nights before she falls asleep. Past medical history is unremarkable except for a simple febrile seizure she had at age 12 months. She walks well, has a vocabulary of more than 50 words, and can put two words together in phrases. Her growth parameters are: height at the 25th percentile, weight at the 25th percentile, and head circumference at the 50th percentile. The remainder of the physical examination findings are normal.

Of the following, the MOST appropriate management at this time is:



A.  electroencephalography

B.  neurologic evaluation

C.  no intervention

D.  ophthalmologic evaluation

E.   psychiatric evaluation


Answer :

C

Head banging is a rhythmic motor habit characterized by repeated striking of the head against a solid object. The reported incidence varies between 3% and 15% in healthy children. On average, the habit usually begins at 8 months of age and disappears by age 4 years.

 Although the etiology of head banging is unclear, it probably is a self-stimulating calming activity. In general, head banging is not caused by sensory deficit. However, children who have cerebral palsy, mental retardation, schizophrenia, autism, otitis media, poor vision, Down syndrome, and Lesch-Nyhan syndrome have a higher incidence of head banging than normal children. These diagnoses at least should be considered in children who have abnormal findings on physical examination or evaluation of development consistent with these diagnoses. Persistence of head banging in normal children after age 4 years also warrants further evaluation.


            There are rarely serious medical complications to head banging. Chronic soft tissue swelling is common in the center of the forehead, but the skin seldom is opened. Skull fractures and cerebral hemorrhage are extremely rare, and their presence should raise the suspicion of another etiology, such as child abuse. An increased incidence of somnambulism and encopresis has been associated with head banging, but development is normal. Cataract formation has been reported in children who experience prolonged, severe head banging; periodic ophthalmologic examination is recommended for those in whom head banging is severe.

            Because the child described in the vignette is developing normally and has normal findings on physical examination, there is no need for encephalography or a neurologic or psychiatric evaluation.

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Q 3



A 10-year-old boy who always has been very active recently started disrupting his class by clowning and not paying attention. At home, he hits his sister and has difficulty following the family routines. His parents have a stable relationship, and there have been no major changes in the family.

Of the following, the MOST appropriate intervention for this boy is a:



A. letter to the school requesting a smaller class size

B. low-sugar diet

C. referral for biofeedback training

D. referral to a mental health clinician

E. trial of stimulant medication

Answer

D



The child described in the vignette exhibits behavioral symptoms that may have a variety of etiologies. It is important to review family interactions to uncover a possible cause for anxiety and resentment in the home. Although the family is unaware of stressors in the home, the boy may have misinterpreted a family occurrence or may have attached more importance to a benign interaction. The school environment also should be reviewed for social and academic stressors. The boy may have educational difficulties that he has learned to mask by clowning and diverting attention in the classroom. He may feel uncomfortable with his peer group and be unable to interact without aggression.

            Further information is needed about this child and his family before treatment options can be considered. Obtaining this information can be time-consuming, requiring investigation into each of his social settings. The time constraints of a busy practice may make it necessary for a primary care pediatrician who identifies a behavioral problem in a patient to refer the child and family to a mental health clinician for more intensive investigation and guidance.

            If the mental health clinician cannot pinpoint any significant educational or psychosocial difficulty, the most appropriate intervention is behavior modification that is designed to assist parents in shaping their child’s behavior. The training supports parents in reinforcing appropriate behaviors and eliminating inappropriate behaviors by ignoring the behavior or punishing the child. Two important elements in behavior modification are increasing the parent’s ability to be positive and reinforcing and helping parents to provide effective discipline that is constructive and not harsh.

            Information about the child and his school is inadequate at this point to request a smaller class size. Dietary interventions and biofeedback are not supported by evidence-based investigations. Prescribing a stimulant medication for this child is inappropriate without more information that supports the diagnosis of attention deficit disorder. Because normal children may respond to stimulant medication and some children who have ADHD may not respond to stimulants, a trial of stimulant medication cannot be used as a diagnostic tool.

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Q 4:



A 12-year-old boy comes to you with his mother for an evaluation of his behavior. His grades have been poor for the last year, and he was suspended for several days for aggression toward classmates. His mother relates that he has trouble sleeping and started a fire in the garage while the family was asleep. When he is angry, he puts the family cat in a pillowcase and throws it across the room.

Of the following, the BEST intervention is to:



A. prescribe a medication for sleep

B. prescribe methylphenidate

C. refer him for a psychiatric evaluation

D. request an educational evaluation

E.  suggest he do community service

Answer

C



The child described in the vignette presents with antisocial behaviors, school difficulty, and sleeping problems. The described behaviors are most consistent with a conduct disorder and warrant a psychiatric referral and evaluation. Other aggressive behaviors consistent with conduct disorder include stealing, vandalism, and assault. Nonaggressive behaviors consistent with conduct disorder include substance abuse, truancy, lying, and running away from home. Conduct disorder must be differentiated from sporadic antisocial behavior that may be part of normal development, oppositional defiant disorder, and psychosis. Conduct disorder and oppositional defiant disorder share elements of negativism and hostility, but conduct disorder is characterized by more severe behavior that violates societal norms. Oppositional defiant disorder is characterized by temper tantrums, defiance of rules, angry/resentful affect, and the use of obscene language.

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Q 5



A mother comes to your office with her 8-year-old boy for a health supervision visit. They have recently moved from out of state. He has poor eye contact, odd intonation, and rapid hand movements. He repeatedly talks about his baseball trading cards and takes out a bag that contains a stack of them. His mother says he is in the second grade and is a strong math student but does have some weakness in reading comprehension. She expresses concern that he has no interest in interacting with children his age.



Of the following, the MOST appropriate diagnosis for this boy is



A. attention-deficit/hyperactivity disorder

B. autism spectrum disorder

C.  intellectual disorder

D. obsessive-compulsive disorder
E. Tourette disorder

Answer

B



The boy described in the vignette has weakness in his verbal and nonverbal communication skills, limited reciprocal social engagement, and restricted and repetitive interests and behavior. These behaviors are most diagnostic of an autism spectrum disorder (ASD).


The boy reported having some academic weakness but no significant impairment in his cognitive skills. These findings are not consistent with a diagnosis of an intellectual disability, which is associated with significant cognitive delays and functional skill deficits. However, intellectual disabilities can be associated with an ASD diagnosis

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Q 6:

A 10-year-old boy in whom you diagnosed attention-deficit/hyperactivity disorder (ADHD) has been receiving stimulant medication daily since he was 7 years old. About 2 years ago, he developed persistent, repetitive throat clearing, and subsequently he has had waxing and waning motor and vocal tics that include eye rolling, grimacing, head bobbing, sniffing, and humming. For the past 2 months, his tics have worsened; he now has a loud squeak and headjerking tic. His mother decided to stop his stimulant medication last week, fearing it might be causing his tics to worsen. Now he is much more hyperactive and is having more behavioral and attentional difficulties at school and home. His tics have not improved.
Of the following, the MOST appropriate treatment plan is to prescribe

A. carbamazepine to see if the movement disorders are seizures
B. daily penicillin to prevent tic exacerbations caused by streptococcal infections
C. haloperidol to treat the tics
D. methylphenidate again to treat the ADHD
E. sertraline to treat the tics

Answer

D


The boy described in the vignette has a tic disorder characterized by multiple waxing and waning motor and vocal tics that have occurred for more than 1 year. Thus, he meets the diagnostic criteria for Tourette syndrome . Most children who have Tourette syndrome also have at least one other diagnosis such as attention-deficit/hyperactivity disorder (ADHD) or an anxiety disorder such as obsessive compulsive disorder (OCD).

 This boy has ADHD and had been treated with psychostimulants with some benefit for 3 years. The decision to stop his stimulant medication, while understandable, was unwise because his symptoms have
worsened since the medication was discontinued.

The severity of tics in Tourette syndrome tends to peak around age 10 years. Thus, the escalation in tics occurring in this boy may be part of the natural history of the disorder. The worsening of tics is not related to the use of psychostimulants, which he has taken for years.

When parents and physicians discontinue stimulants in children who have Tourette syndrome and ADHD, the ADHD symptoms generally worsen, which leads to increased stress on the child. Tics do not improve and may worsen due to the increased stress.

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Q 7:



The mother of one of your patients is in the process of getting a divorce and has just moved into
a small apartment. Due to her new work schedule, she has not been able to unpack the boxes
left in the kitchen. She brings her 4-year-old daughter to your office because the child cut herself
with a knife trying to open one of the unpacked boxes. The mother is visibly upset. After you
bandage the daughter’s injured hand, you sit down to talk with the mother.
Of the following, you are MOST likely to

A. explore what support system the mother has to help her family settle into their new home
B. recommend that the mother place her child in time-out for playing with the knife
C. recommend that the mother have a psychiatric evaluation
D. refer the mother to parenting classes
E. tell the mother that you are obligated to report her to the child welfare agency

Answer 

A



The woman described in the vignette is under substantial stress. The pediatrician can be
most helpful by identifying support systems in the woman’s family or community to assist her
during this difficult time. This can promote her ability to provide a stable, nurturing home for her
child. If necessary, the pediatrician also can provide age-appropriate anticipatory guidance
regarding injury prevention

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Q 8:

One of your 2-year-old patients has prolonged crying and screaming episodes every time her
parents deny her access to something she desires. The mother reports that the girl often throws
herself on the floor, kicking and thrashing about for long periods of time. She asks you how she
should handle her daughter’s behavior.
Of the following, your BEST suggestion is that the parents should

A. consider giving in to the girl only when she is outside of the home to avoid a major tantrum
B. give the daughter 10 minutes of time-out for each temper tantrum
C. move the girl to a safe place if needed and ignore her when she has a tantrum
D. offer the child a treat if she calms down
E. physically restrain the child until the tantrum is over


Answer

C


Almost every child has temper tantrums at some time. Tantrums occur when a child is frustrated
beyond his or her ability to manage feelings. Studies show that up to 80% of toddlers have a
weekly tantrum. The parents should be asked about the events that tend to lead to a tantrum,
what behaviors occur during the tantrum, how they respond, and what the outcome is. An
appropriate behavioral management plan may be developed if the parents understand the
developmental issues that lead to a tantrum.

If a tantrum results from a child being frustrated by a task, distracting or redirecting the child
to a task in which he or she can succeed may be helpful. If a tantrum occurs at a regular time,
such as before meals or prior to going to bed, parents need to be advised that the child’s
physical state (hunger, fatigue) may be a factor. A routine and structured environment (eg,
regular meals and bedtimes appropriate for age) may help decrease the child’s tantrums. For
tantrums resulting from the child being denied access to a desired object, as described for the
child in the vignette, ignoring the behavior is the most appropriate response. Parents should be
cautioned that the first response to this action may be escalating tantrum behavior. Such
behavior tends to last a few days and eventually decreases and disappears.
Management of tantrums requires setting of limits, which should include positive
reinforcement for appropriate behavior (time-in) and negative reinforcement or removal from a
situation for undesired behavior. Parents should be consistent in their response to tantrums both
inside and outside the home and not give in to the child or offer a treat, which serves as
reinforcement of the tantrums. It is important to determine that the child is not in danger of hurting
himself or herself during the tantrum. 

Children should be left alone in a safe place until they can calm down. Such a procedure should not entail a fixed amount of time; the purpose is to allow the child to self-egulate his or her behavior. As soon as the child calms down, the parent may engage the child in social interaction and provide praise for the calmer state. The use of physical restraint may strate or possibly injure the child. Time-out is a management technique that is used to address specific behaviors that are under the child’s control (eg,  iting). Experts recommend that the time-out last 1 minute per year of the child’s age. The child who has notable oppositional behavior that occurs in multiple settings with multiple caregivers and results in impairment of functioning may require referral for behavior
management

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Q 9:

.A 3-year-old boy has a history of biting his parents’ cheeks when he does not get his way, which
they have always considered cute, calling it “love bites.” His child care teacher has informed the
parents that he is frequently biting other children. The boy’s parents are concerned that he may
be removed from his child care program and ask for your advice about how to stop this
behavior.
Of the following, the BEST response is to

A. advise the parent to change child care centers
B. instruct the parents to set up a reward system for not biting
C. recommend treatment with a stimulant to help decrease the behavior quickly
D. take the child aside and explain that his behavior is not acceptable and may cause him to be
removed from child care
E. tell the parents it is acceptable to gently bite the child or tap his backside to stop this behavior
quickly

Answer

B


The child described in the vignette requires behavioral strategies to stop his biting. The initial
intervention should involve watching the child and providing positive attention for appropriate
behavior. He should be redirected when he gets frustrated or angry. When he bites, he should
be told firmly “no” and removed from positive attention, such as placing him in a time-out
situation. Prior to considering removal from the child care program, the parents should meet with
the teacher to develop a consistent behavioral approach when the child bites. The parents
should not bite or hit the child in response; this causes fear and anger in the child and leads to
feelings of guilt in the parent. Stimulants are not indicated in the treatment of biting. The child
likely will be unable to understand lengthy explanations about why he should not bite.


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