Childhood Psychiatric Disorders Qs

a 3-year-old boy is brought to your office by his mother due to abnormal behavior. She reports that he does not appear to respond to affection, does not look her in the eyes, and constantly lines up his toys. He becomes agitated when she tries to take him away from his toys or if the mother cooks a different meal for dinner. On physical examination, he does not respond to questions and is distracted by the texture of the exam-table cloth. A Conductive hearing loss B Attention-deficit disorder C Autism D Manic- depressive disorder E Dyslexia

C Autism

a 10-year-old boy whose parents c/o constant arguments. His parents state that he has "been a handful." He argues all the time. He is always angry and is easily agitated. He seems to enjoy making others upset. At school, he does not listen to his teachers and argues with them all the time. His parents report that they are "fed up" with him and his behavior is "putting a lot of strain on our marriage." Past medical history is significant for ADHD with panic disorder. what is this disorder?

Oppositional defiant disorder ~ a 10-year-old boy whose parents c/o constant arguments. His parents state that he has "been a handful." He argues all the time. He is always angry and is easily agitated. He seems to enjoy making others upset. At school, he does not listen to his teachers and argues with them all the time. His parents report that they are "fed up" with him and his behavior is "putting a lot of strain on our marriage." Past medical history is significant for ADHD with panic disorder.

A 4-year-old boy is noted to have impaired language development, compulsive repetitive behavior, impaired intelligence, and a preoccupation with inanimate objects. The most likely diagnosis is A Conductive hearing loss B Attention-deficit disorder C Autism D Manic- depressive disorder E Dyslexia

C Autism Autism is a condition that is associated with abnormal social relationships, impaired language development and understanding, compulsive repetitive behavior with a resistance to change, and impaired intelligence; most affected individuals are in the mentally retarded range. The condition affects boys more frequently than girls and, in most cases, manifests itself before 1 year of age. Symptoms include a lack of attachment; preoccupation with inanimate objects; avoidance of eye contact; resistance to change; outbursts of temper; repetitive, often self-destructive acts; delayed speech development or total muteness; and seizures in severely impaired children. Neurologic examination fails to show focal findings. CT scans of the head may show enlargement of the ventricles, and EEG studies are usually unremarkable. Most children are brought to their doctors because of poor speech development. Treatment involves psychotherapy; however, results have been limited with regard to improving the child's deficiencies and behavior. Most children require special schooling. Mainstream treatment consists of early, intensive education for parents, focusing on behavior and communication disorders. A highly structured environment with intensive individual instruction should be encouraged. Laboratory, metabolic, or genetic tests and diagnostic imaging provide little useful information, although an EEG is indicated in children in whom epilepsy is suspected. No specific pharmacologic therapies are available, but many patients do not require medication. When needed, medication is generally used for a particular manifestation or constellation of symptoms. Families may benefit from ongoing counseling and support and specific instructions for dealing with tantrums and destructive behavior. Parents should be cautioned about costly and often questionable dietary, medical, and other unconventional therapies.

Which of the following statements is correct about ADHD? A ADHD is one of the most heritable psychiatric disorders B ADHD is more common in girls than boys C ADHD is rarely associated with other clinical diagnoses D ADHD is largely caused by environmental exposure

A ADHD is one of the most heritable psychiatric disorders Studies estimate the mean heritability of ADHD to be 76%, indicating that ADHD is one of the most heritable psychiatric disorders. Hypotheses exist that include in utero exposures to toxic substances, food additives or colorings, or allergic causes. However, diet, especially sugar, is not a cause of ADHD. How much of a role family environment has in the pathogenesis of ADHD is unclear, but it certainly may exacerbate symptoms. ADHD is associated with a number of other clinical diagnoses. Studies have demonstrated that many individuals have both ADHD and antisocial personality disorder. These individuals are at higher risk for self-injurious behaviors. ADHD is also linked to addictive behavior. In children, ADHD is three to five times more common in boys than in girls. Some studies report an incidence ratio of as high as 5:1. The predominantly inattentive type of ADHD is found more commonly in girls than in boys. For more on the presentation of ADHD, read here.

A 9-year-old boy is brought to the physician by his mother because of poor performance in school for the last year. He has difficulty sitting still at his desk, does not follow the teacher's instructions, and frequently blurts out answers in class. He often gets sent outside the classroom for failing to work quietly. At hockey practice, he does not wait his turn and has difficulty listening to his coach's instructions. His mother reports that he is easily distracted when she speaks with him and that he often forgets his books at home. Physical examination shows no abnormalities. Which of the following is the most appropriate pharmacotherapy? A Atomoxetine B Suvorexant C Buspirone D Risperidone E Fluoxetine F Varenicline

A Atomoxetine Atomoxetine is a nonstimulant drug for treating ADHD and is prescribed for patients who cannot tolerate stimulants, such as methylphenidate. Atomoxetine carries a black-box warning for increased suicidal ideation in children and adolescents, so treatment must be monitored closely. Other nonstimulant drugs approved for the treatment of ADHD include clonidine and guanfacine.

A 5-year-old boy is brought to the physician by his mother because he does not "listen to her" anymore. The mother also reports that her son cannot concentrate on any tasks lasting longer than just a few minutes. Teachers at his preschool report that the patient is more active compared to other preschoolers, frequently interrupts or bothers other children, and is very forgetful. He was born at term via vaginal delivery and has been healthy except for 3 episodes of acute otitis media at the age of 2 years. He has met all developmental milestones. His mother has major depressive disorder and his father has Graves' disease. He appears healthy and well nourished. Examination shows that the patient turns his head briefly towards the examiner and sometimes makes eye contact when spoken to but does not respond to direct questions and continues to play with and touch objects in the physician's office. He interrupts his mother and the physician frequently during the examination to express his wish to go outside and eat a snack. The remainder of the examination shows no abnormalities. Which of the following is the most appropriate next step in management? A Behavior therapy B Methimazole C Fluoxetine D Hearing aids E Atomoxetine F Methylphenidate

A Behavior therapy Behavioral interventions, including behavior therapy and socio-educational measures (e.g., creation of a low-stimulus environment, providing support for learning disabilities), are considered the first-line treatment for ADHD in preschool-aged children (4-5 years of age). Behavior therapy is most successful when guided by the parents; for this reason, behavioral parent training (BPT) is recommended for all parents of children with ADHD. Medications such as methylphenidate are only recommended in patients who do not respond to these behavioral interventions.

Which of the following is an evidence-supported concern in children with ADHD? A Comorbid bipolar disorder B Increased risk for cardiac conditions C An associated underlying immunodeficiency disease D Foods that contain food coloring or that are high in simple sugars, which exacerbate symptoms

A Comorbid bipolar disorder ADHD can be comorbid with the following conditions: Other developmental learning disorders Conduct disorder or oppositional defiant disorder Bipolar disorder (Studies in the United States have shown a comorbidity prevalence that ranges from 2% to 23%.) Tourette syndrome Pervasive developmental disorder Mental retardation For decades, speculation and folklore have suggested that foods containing preservatives or food coloring, or foods high in simple sugars, may exacerbate ADHD. Many controlled studies have examined this question. To date, no adequate dataset has confirmed the speculation. For more on long-term care of ADHD,

A 7-year-old boy wets the bed on most nights. He does not experience daytime symptoms. Which of the following is the preferred pharmacological agent to decrease the incidence of bedwetting? A Desmopressin B Phenytoin C Pramipexole D Hyoscyamine E Oxybutynin

A Desmopressin When the parents and child are interested and motivated to work toward long-term management, initial management of enuresis involves the treatment of coexisting conditions, clarification of goals and expectations, provision of education/advice, and motivational therapy. It is reasonable to recommend active therapy to children with monosymptomatic nocturnal enuresis who have no improvement after three to six months of initial management if enuresis continues to be a problem for the child and family (eg, is associated with diminished self-esteem, prevents the child from attending sleepovers). Initial active therapies include enuresis alarms and desmopressin (a synthetic vasopressin analog).

Which of the following is not usually associated with autism? A Normal IQs B Echolalia C Repetitive movements D Self-injury behaviors E Seizures

A Normal IQs The impairments noted in autistic persons are varied and result in good skills in some areas and poor skills in others. Echolalia, the involuntary repetition of a word or a sentence just spoken by another person, is a common feature of language impairment that, when present, may cause language skills to appear better than they really are. There may also be deficiencies in symbolic thinking, stereotypic behaviors (e.g., repetitive nonproductive movements of hands and fingers, rocking, meaningless vocalizations), self-stimulation, self-injury behaviors, and seizures. Mental retardation

A 7-year-old boy is brought to the physician because of repetitive, involuntary blinking, shrugging, and grunting for the past year. His mother states that his symptoms improve when he is physically active, while tiredness, boredom, and stress aggravate them. He has felt increasingly embarrassed by his symptoms in school, and his grades have been dropping from average levels. He has met all his developmental milestones. Vital signs are within normal limits. Mental status examination shows intact higher mental functioning and thought processes. Excessive blinking, grunting, and jerking of the shoulders and neck occur while at rest. The remainder of the examination shows no abnormalities. This patient's condition is most likely associated with which of the following findings? . A Excessive impulsivity and inattention B Defiant and hostile behavior toward teachers and parents C Poor comprehension of numbers D Feelings of persistent sadness and loss of interest E Chorea and hyperreflexia F Recurrent episodes of intense fear

A. Excessive impulsivity and inattention. Excessive impulsivity, as well as hyperactivity and inattention with impairment of social, occupational, or academic performance are the core features of attention deficit hyperactive disorder (ADHD). About 60% of patients with Tourette syndrome develop concomitant ADHD, making it the most common comorbidity. Obsessive-compulsive disorders (OCD) are also common in patients with Tourette syndrome.

a 9-year-old boy who is brought by his mother after the child was suspended from school for being disruptive during class. The teacher noted that the patient is always fidgeting, has difficulty concentrating, and does not complete assignments. His mother notes that he often gets up and runs around the house when she is trying to call everyone for dinner and that this has been going on since he was 6 years old

ADHD a 9-year-old boy who is brought by his mother after the child was suspended from school for being disruptive during class. The teacher noted that the patient is always fidgeting, has difficulty concentrating, and does not complete assignments. His mother notes that he often gets up and runs around the house when she is trying to call everyone for dinner and that this has been going on since he was 6 years old Key Points: •Hyperactivity, impulsivity, or inattentiveness manifesting prior to age 12 years. •> 6 symptoms of inattention, hyperactivity-impulsivity, developmentally inappropriate and duration of symptoms > 6 months •Symptoms must occur in more than one setting (example school and home) •Highest in preschoolers, 7% of school-age children; decreases with age; boys predominate; between 18% and 35% of affected children have an additional psychiatric disorder. •ADHD is one of the most heritable psychiatric disorders: studies estimate the mean heritability of ADHD to be 76% Tx 1st line meds - caution: wt. loss & ↓ growth with stimulants! •methylphenidate (Ritalin, Concerta, Daytrana) •dexmethylphenidate (Focalin) •amphetamine/dextroamphetamine (Adderall, Dexedrine) •atomoxetine (Strattera) selective norepinephrine atomoxetine (Strattera) selective norepinephrine reuptake inhibitor (non-stimulant)

Which of the following is recognized as a symptom of the predominantly inattentive type of ADHD? A Fidgeting with or tapping hands or feet B Often loses things necessary for tasks or activities C Excessive talking D

B Often loses things necessary for tasks or activities Question 8 Explanation: The three types of ADHD are predominantly inattentive, predominantly hyperactive/impulsive, and combined. The specific criteria for ADHD are:Inattentive: This must include at least six of the following symptoms of inattention that must have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level:Often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activitiesOften has difficulty sustaining attention in tasks or play activitiesOften does not seem to listen to what is being saidOften does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions)Often has difficulties organizing tasks and activitiesOften avoids or strongly dislikes tasks (such as schoolwork or homework) that require sustained mental effortOften loses things necessary for tasks or activities (school assignments, pencils, books, tools, or toys)Often is easily distracted by extraneous stimuliOften forgetful in daily activitiesHyperactivity/impulsivity: This must include at least six of the following symptoms of hyperactivity-impulsivity that must have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level:Fidgeting with or tapping hands or feet, squirming in seatLeaving seat in classroom or in other situations in which remaining seated is expectedRunning about or climbing excessively in situations where this behavior is inappropriate (in adolescents or adults, this may be limited to subjective feelings of restlessness)Difficulty playing or engaging in leisure activities quietlyUnable to be or uncomfortable being still for extended periods of time (may be experienced by others as "on the go" or difficult to keep up with)Excessive talkingBlurting out answers to questions before the questions have been completedDifficulty waiting in lines or awaiting turn in games or group situationsInterrupting or intruding on others (for adolescents and adults, may intrude into or take over what others are doing)OtherOnset is no later than age 12 yearsSymptoms must be present in two or more situations, such as school, work, or homeThe disturbance causes clinically significant distress or impairment in social, academic, or occupational functioningDisorder does not occur exclusively during the course of schizophrenia or other psychotic disorder and is not better accounted for by mood, anxiety, dissociative, personality disorder, or substance intoxication or withdrawal

Which of the following statements is true regarding Tourette's syndrome? A Only 1% of the population is affected B Tourette's syndrome is a familial disorder C Patients with tic disorders rarely have other associated psychological conditions D TCAs are the treatment of choice E The long-term prognosis for treatment is poor

B Tourette's syndrome is a familial disorder Tic disorders are rather common in the general population. Once thought to be rare, Tourette's syndrome is now known to be a more common disorder that represents the most complex and severe manifestation of the spectrum of tic disorders. Tourette's syndrome is a chronic familial disorder with a fluctuating course; the long-term outcome is generally favorable. It is more common among men than women. Although the exact underlying pathology has yet to be determined, evidence indicates a disorder localized to the frontal-subcortical neural pathways. Tourette's syndrome is associated with ADHD, OCD, behavior problems, and learning disabilities. These associated conditions can make the management of Tourette's syndrome more difficult. Use of antipsychotic medications (resperidone, pimozide, olanzapine, and haloperidol) and clonidine can be effective but may be associated with significant side effects.

An 8-year-old girl is brought to the physician because of repetitive involuntary movements, including neck twisting, grimacing, grunting, and blinking, for the past 18 months. Her symptoms seem to improve with concentration and worsen with fatigue. During the past 3 months, they have become so severe that she has missed many school days. Her mother says she also has too much anxiety about her involuntary movements to see her friends and prefers staying home in her room. Her birth and development until 18 months ago were normal. Her father has bipolar disorder. Vital signs are within normal limits. Mental status examination shows intact higher mental function and thought processes. Neurological examination shows multiple motor and vocal tics. Physical examination is otherwise within normal limits. Which of the following is the most appropriate initial pharmacotherapy for this condition? A Alprazolam B Pimozide C Fluoxetine d Chlorpromazine

B ~ Pimozide This child presents with symptoms of Tourette syndrome, a condition characterized by involuntary vocal and motor tics. FDA-approved medications for the treatment of tics are haloperidol, pimozide, and aripiprazole. Other dopamine receptor blockers (e.g., fluphenazine and risperidone) have shown a similar response rate in reducing the frequency and intensity of tics. However, dopamine receptor blockers are no longer preferred because of the risk of tardive dyskinesia. Instead, dopamine depleters (e.g., tetrabenazine) are used to treat tic-predominant Tourette syndrome while alpha agonists (e.g., guanfacine or clonidine) are used to treat patients with concurrent Tourette syndrome and attention deficit hyperactivity disorder.

Which of the following disorders often appear together in the same individual at various life stages? A mental retardation, attention-deficit/ hyperactivity disorder (ADHD), and learning disability B childhood depression, ADHD, and early-onset adult schizophrenia C ADHD, conduct disorder, and antisocial personality disorder D adjustment disorder, ADHD, and major depression E ADHD, bipolar disorder, and conduct disorder

C ADHD, conduct disorder, and antisocial personality disorder ADHD commonly leads to conduct disorder. Adolescents who have conduct disorder are predisposed to the development of antisocial personality disorder or alcoholism as adults.

Which of the following is generally accepted as the most effective first-line therapeutic option in children with ADHD? A Norepinephrine reuptake inhibitors B Behavioral psychotherapy alone C Stimulants and cognitive therapy D Cognitive therapy alone

C Stimulants and cognitive therapy Dexedrine or Ritalin In children with ADHD, stimulant therapy is more effective than behavioral therapy or regular community care (medication management by primary care provider). This finding has been borne out for the treatment of adults with ADHD as well. Atomoxetine (Strattera®) has become a second-line—and in some cases, first-line—treatment in children and adults with ADHD because of its efficacy and classification as a nonstimulant. However, studies have reported that the overall effect of atomoxetine has not been as extensive as that reported for stimulants. Behavioral psychotherapy is often effective when used in combination with an effective medication regimen. Behavioral therapy or modification programs can help diminish uncertain expectations and increase organization. Metacognitive therapy in adults involves the principles and techniques of cognitive and behavioral therapies to enhance time management. In doing so, these have made adult patients with ADHD better able to counter the anxiety and depressive symptoms they experience in task performance. For more on the treatment of ADHD, read here.

A mother brings her 6-year-old son to the office for a complete assessment. She states that "there is something very wrong with him." He just sprinkled baby powder all over the house, and last night he opened a bottle of ink and threw it on the floor. He is unable to sit still at school, is easily distracted, has difficulty waiting his turn in games, has difficulty in sustaining attention in play situations, talks all the time, always interrupts others, does not listen when talked to, and is constantly shifting from one activity to another. As you enter the examining room, the child is in the process of destroying it. On examination (what examination you can manage), you discover that there are no physical abnormalities demonstrated. What is the most likely diagnosis in this patient? A mental retardation B childhood depression C attention-deficit/hyperactivity disorder (ADHD) D maternal deprivation E childhood schizophrenia

C attention-deficit/hyperactivity disorder (ADHD) ADHD is characterized by a pattern of behavior, present in multiple settings (e.g., school and home), that can result in performance issues in social, educational, or work settings. As in DSM-V, symptoms will be divided into two categories of inattention and hyperactivity and impulsivity that include behaviors like failure to pay close attention to details, difficulty organizing tasks and activities, excessive talking, fidgeting, or an inability to remain seated in appropriate situations. Children must have at least six symptoms from either (or both) the inattention group of criteria and the hyperactivity and impulsivity criteria, while older adolescents and adults (over age 17 years) must present with five.

a 4-year-old girl is brought to the emergency department by her mom because the child was found to be lethargic after being picked up from a new daycare. The child has been attending the new daycare for the past week. Medical history is noncontributory. Physical examination shows multiple bruises on the buttocks, a small circular burn mark on the arm, and retinal hemorrhages. A chest radiograph is obtained and shows a right-sided rib fracture.

Child abuse

he most definitive treatment for primary enuresis is A oxybutynin chloride (Ditropan) B imipramine (Tofranil) C trimethoprim-sulfamethoxazole (Bactrim) D desmopressin (DDAVP)

D desmopressin (DDAVP) Intranasal desmopressin is effective in 50% of patients treated and is the treatment of choice. Imipramine is an older form of treatment that is moderately effective, but many patients relapse when therapy is stopped. This is no longer considered the treatment of choice.

a 16-year-old male who has demonstrated significant behavioral and impulsive problems since early childhood, which were manifested more prominently when he was four. During this time he was removed from his mothers care due to her continuous substance abuse. She reported using alcohol, cocaine, and crack cocaine during her pregnancy. He has a history of repeated violations of school rules and disruption in class. He often was aggressive and cut school. He also reported torturing animals and doing "sexual things" to them. He once set his grandmother's bed on fire while she was sleeping in it. Another disclosure involved playing in the backyard of his grandmother's home where he burned several toys. Psychological testing was carried out and his results indicated an average IQ using the Wechsler Intelligence Scale for Children. His scale scores included a verbal score of 93, performance score of 104 and a full scale score of 95. Further testing revealed his struggles with an extremely low self-esteem. He also provided somewhat odd answers on a sentence completion assessment, mentioning several times "that I wish I was never born."

Conduct disorder a 16-year-old male who has demonstrated significant behavioral and impulsive problems since early childhood, which were manifested more prominently when he was four. During this time he was removed from his mothers care due to her continuous substance abuse. She reported using alcohol, cocaine, and crack cocaine during her pregnancy. He has a history of repeated violations of school rules and disruption in class. He often was aggressive and cut school. He also reported torturing animals and doing "sexual things" to them. He once set his grandmother's bed on fire while she was sleeping in it. Another disclosure involved playing in the backyard of his grandmother's home where he burned several toys. Psychological testing was carried out and his results indicated an average IQ using the Wechsler Intelligence Scale for Children. His scale scores included a verbal score of 93, performance score of 104 and a full scale score of 95. Further testing revealed his struggles with an extremely low self-esteem. He also provided somewhat odd answers on a sentence completion assessment, mentioning several times "that I wish I was never born."

Which of the following is required for a diagnosis of ADHD? A Prolonged lethargy lasting at least 3 months B Presence of a comorbid psychiatric disorder C Positive findings on brain imaging (such as functional MRI or single-photon emission CT [SPECT]) D At least six symptoms of inattention or hyperactivity-impulsivity (or both) that have persisted for at least 6 months

D At least six symptoms of inattention or hyperactivity-impulsivity (or both) that have persisted for at least 6 months

Tourette's syndrome is associated with which one of the following comorbidities? A Cardiac arrhythmias B Partial or complex seizures C Hypertension D Attention-deficit disorder E Hypothyroidism

D Attention-deficit disorder Tourette's syndrome is often associated with psychiatric comorbidities, mainly attention-deficit/ hyperactivity disorder and obsessive-compulsive disorder. The other conditions listed are not associated with Tourette's syndrome. ADHD and OCD~

A 5-year-old girl is brought to the physician by her parents because of difficulty at school. She does not listen to her teachers or complete assignments as requested. She does not play or interact with her peers. The girl also ignores her parents. Throughout the visit, she draws circles repeatedly and avoids eye contact. Physical and neurological examination shows no abnormalities. Which of the following is the most likely diagnosis? A Attention-deficit/hyperactivity disorder B Oppositional defiant disorder C Age-appropriate behavior D Autism spectrum disorder E Childhood disintegrative disorder F Rett syndrome

D Autism spectrum disorder

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? A Attention deficit hyperactivity disorder B Oppositional defiant disorder C Fragile X syndrome D Autism spectrum disorder E Hearing impairment F Conduct disorder G Rett syndrome H Age-appropriate behavior

D Autism spectrum disorder Although clinical presentation varies widely, autism spectrum disorder (ASD) is characterized by impairment in social interaction and restrictive patterns of behavior or interests. This patient's trouble communicating, inattentiveness, refusal to speak and make eye contact, and fixation on and intense attachment to certain objects (red toy cars) and repeated actions are all typical of patients with ASD. While the exact cause is unknown, twin studies strongly suggest a genetic predisposition.

A 15-year-old boy is brought to the physician because his parents are increasingly desperate about his behavior. Last week, he was caught smoking marijuana outside a mall by the police. Over the past year, he has been suspended from school 3 times for bullying younger classmates, stealing his friend's wallet, and breaking the windows of the school cafeteria. He says that his classmates deserve to be bullied "because they are wimps." He is a high school sophomore, and his performance at school is poor. His teachers report that he regularly loses his temper and often skips classes. When asked about his school performance, he responds, "My classes are so lame. I would much rather hang out with my friends." His mother says, "He is such a troublemaker. I don't know what to do with him anymore." On mental status examination, attention and concentration are poor. Which of the following is the most likely diagnosis? A Oppositional defiant disorder B Intermittent explosive disorder C Disruptive mood dysregulation disorder D Conduct disorder E Antisocial personality disorder F Attention-deficit hyperactivity disorder

D Conduct disorder.. This patient meets the diagnostic criteria for conduct disorder (CD), which include aggression (e.g., bullying, arguing with teachers), certain criminal behaviors (e.g., theft, destruction of property), and serious rule violation (e.g., truancy). To make the diagnosis, the disturbance in behavior must last at least 12 months and significantly impair social, academic, or occupational functioning, as is the case in this patient. CD typically presents during childhood or adolescence but may persist beyond 18 years of age and result in antisocial personality disorder. It may be preceded by oppositional defiant disorder (ODD). Risk factors for developing CD include genetic, psychological, and social factors (e.g., family instability). CD is also associated with adolescent drug use (e.g., marijuana). Treatment involves cognitive behavioral therapy, parent management training, social skills training, and pharmacotherapy.

Which of the following is (are) true regarding the prevalence of the disorder? A prevalence rates are higher in preschool children than in school-age children B affected boys outnumber girls in surveys of school-age children C prevalence rates decline as a cohort of children ages into adulthood D a, b, and c E none of the above

D a, b, and c Some studies suggest that between 14% and 20% of preschool and kindergarten boys and approximately one third as many girls have ADHD. In elementary school studies, 3% to 10% of students have ADHD symptoms. Affected boys outnumber girls until young adulthood, when women predominate.

Who is the person who usually makes this diagnosis? A the child psychiatrist B the family physician C the mother or father D the schoolteacher E the grandparents

D the schoolteacher The most common person to make the diagnosis of ADHD is the schoolteacher. There is considerable controversy concerning the fact that many children who are hyperactive take medication because of the remarks or diagnosis of the schoolteacher. There may be some truth to this statement. Inexperienced or overly critical teachers may in fact confuse normal age-appropriate overactivity with ADHD. However, on the basis of a study by the Centers for Disease Control and Prevention, the rate of parent-reported ADHD among children between the ages of 4 and 17 years is increasing. Between 2003 and 2007, there was a 22% increase in parent reporting from 7.8% to 9.5%.

a 25-year-old woman who comes to your office for a new patient visit. Her complaints are 6 months of constant pelvic pain and low back pain, intermittent myalgias, insomnia for "many years," and feeling tired. When you ask about bruises of varying ages on arms, legs, and face, she notes that she is clumsy and bumps into things a lot. Her husband accompanies her to the visit and refuses to leave the room for the physical examination. On pelvic examination, purulent cervical discharge is noted, along with cervical motion tenderness. Her husband inquires as to why you are using so many tubes for laboratory specimens.

Domestic violence a 25-year-old woman who comes to your office for a new patient visit. Her complaints are 6 months of constant pelvic pain and low back pain, intermittent myalgias, insomnia for "many years," and feeling tired. When you ask about bruises of varying ages on arms, legs, and face, she notes that she is clumsy and bumps into things a lot. Her husband accompanies her to the visit and refuses to leave the room for the physical examination. On pelvic examination, purulent cervical discharge is noted, along with cervical motion tenderness. Her husband inquires as to why you are using so many tubes for laboratory specimens.

Which of the following is (are) associated with ADHD disorder described? A feelings of low self-esteem B feelings of depression C impaired interpersonal relationships D a reduction in life successes E all of the above

E Commonly associated features of ADHD are low self-esteem, feelings of depression, feelings of demoralization, and lack of ability to take responsibility for one's actions. In social situations, these young children are immature, bossy, intrusive, loud, uncooperative, out of synchrony with situational expectations, and irritating to both adults and peers. Children with ADHD are more likely to sustain severe injuries than are those without ADHD.

A 13-year-old boy is brought to the physician by his parents for the evaluation of multiple behavioral problems. The parents report that their son has been bullying several classmates at school over the past year. During this period, he has been accused twice of stealing items from a local store. He has also beaten up the neighbor's son for no obvious reason. The parents state that they had to give up their dog for adoption after finding out that their son was torturing him. There is no personal or family history of serious illness. He attends a local middle school and his performance at school is poor compared to his classmates. He often forgets to do his homework and argues with his teachers. He was also caught smoking cigarettes. Vital signs are within normal limits. Physical examination shows no abnormalities. He has poor attention and does not answer some of the questions. For questions he answers affirmatively about his actions, he sometimes replies, "So what?." Which of the following conditions is this patient most likely to develop? A Major depressive disorder B Obsessive-compulsive disorder C Anxiety disorders D Bipolar disorder E Antisocial personality disorder F Early-onset dementia

E Antisocial personality disorder Up to 70% of individuals with a conduct disorder will eventually develop antisocial personality disorder. The criteria for a conduct disorder must be met before the age of 15 years for a patient to be diagnosed with antisocial personality disorder during adulthood. Both antisocial personality disorder and conduct disorder have similar features such as deceitfulness, aggressiveness, and a failure to accept the rights of others or to conform to societal norms. The risk of antisocial personality disorder is greater with childhood-onset conduct disorder when compared with onset during adolescence. Other conditions that are strongly associated with a conduct disorder include ADHD and substance abuse.

A 23-year-old man comes to the physician for a routine health maintenance examination. He feels well. He was recently fired from his job as a cashier because of mistakes and absenteeism. He says that he finds it difficult to maintain focus on any task and often feels restless. He admits that he often forgets to pay his bills and often misplaces his cell phone and keys. He has had poor academic performance and dropped out of high school at 15 years of age. He drinks three to four beers on weekends and does not smoke or use illicit drugs. He is sexually active with one male partner and uses condoms inconsistently. His mother has a history of opioid use disorder. Vital signs are within normal limits. Physical examination shows no abnormalities. Mental status examination shows a normal mood and a reactive affect. A diagnosis of attention deficit hyperactivity disorder (ADHD) with a predominantly inattentive presentation is made. The physician explains the implications of the diagnosis, various treatment options, and the adverse effects of each treatment. The patient is concerned about his risk for a substance use disorder given his family history. Which of the following is the most appropriate pharmacotherapy for this patient? A Guanfacine B Nortriptyline C Venlafaxine D Dextroamphetamine E Atomoxetine F Methylphenidate

E Atomoxetine Nonstimulant drugs, such as atomoxetine, are the most appropriate pharmacotherapy for patients with ADHD who have a personal history of substance use disorder or are concerned about the addictive effects of stimulant drugs. Although nonstimulant drugs are typically less effective and have a delayed onset of therapeutic action (1-2 weeks) compared to stimulant drugs (e.g., methylphenidate, which acts in ≤ 1 hour), they are not associated with drug dependence or misuse. Bupropion is also an acceptable nonstimulant drug to treat ADHD, especially for patients with concomitant major depressive disorder.

Conduct disorder appears to result from an interaction of which of the following factors? A temperament B attention to problem behavior and ignoring of good behavior C association with a delinquent peer group D a and c E a, b, and c

E a, b, and c Conduct disorder appears to result from an interaction among the following factors: (1) temperament, (2) parents who provide attention to problem behavior and ignore good behavior, (3) association with a delinquent peer group, (4) a parent "role model" of impulsivity and rule-breaking behavior, (5) genetic predisposition, (6) marital disharmony in the family, (7) placement outside of the home as an infant or toddler, (8) poverty, and (9) low intelligence quotient or brain damage.

The differential diagnosis of this disorder includes which of the following? A adjustment disorder B bipolar disorder C anxiety disorder D childhood schizophrenia E a, b, and c

E a, b, and c Question 4 Explanation: The differential diagnosis of ADHD includes the following: (1) adjustment disorder (an identifiable stressor is identified at home and the duration of symptoms is less than 6 months); (2) anxiety disorder (instead of or in addition to the diagnosis of ADHD); (3) bipolar disorder (bipolar disorder in children may be manifested as a chronic mixed affective state marked by irritability, overactivity, and difficulty concentrating); (4) mental retardation; (5) a specific developmental disorder; (6) drugs (phenobarbital prescribed for children as an anticonvulsant and theophylline prescribed for asthma); (7) systemic disorders (hyperthyroidism); and (8) other disruptive behavioral disorders, including oppositional defiant disorder (ODD) and conduct disorder. The differential diagnosis of ADHD does not include childhood schizophrenia.

Which treatment( s) is (are) used to manage symptoms of conduct disorder? A behavioral therapy B mood stabilizers C alpha agonists D beta blockers E all of the above

E all of the above mood stabilizers / antipsychotic alpha agonists ~ guanfacine beta blockers ~ propranolol Although behavioral therapy is the mainstay for treatment of the core symptoms of conduct disorder, target symptoms such as aggression and agitation may be treated with medications such as alpha agonists, mood stabilizers, beta blockers, and antipsychotics. Of course, it is also crucial to identify and to treat comorbid disorders.

a 9-year-old boy who is brought by his mother after the child was suspended from school for being disruptive during class. The teacher noted that the patient is always fidgeting, has difficulty concentrating, and does not complete assignments. His mother notes that he often gets up and runs around the house when she is trying to call everyone for dinner and that this has been going on since he was 6 years old Which of the following are pharmacologic treatment options in the disorder described? A methylphenidate or its derivatives B dextroamphetamine or amphetamine derivatives C magnesium pemoline D modafinil E a or b

E The pharmacologic agents of choice for the management of ADHD are the stimulant medications (1) methylphenidate or derivatives and (2) dextroamphetamine or amphetamine derivatives. As many as 96% of children with ADHD have at least some positive behavioral response to stimulants, of which methylphenidate and dextroamphetamine are the two tried and true medications. Both are available in various formulations, including longer acting derivatives. Methylphenidate is available in short-acting (Ritalin), intermediate-acting (Ritalin-SR), and long-acting (Concerta) preparations. Dextroamphetamine is also available as short-acting (6 to 8 hours; Dexedrine and Adderall) and long-acting (Dexedrine spansules and Adderall XR) formulations. Unfortunately, side effects may limit efficacy or require discontinuation of medication in some children. Lower weight-adjusted doses may be required for both preschool children and adolescents than for school-age children, with a greater likelihood of side effects and somewhat lower therapeutic efficacy. Pemoline was removed from the market because of liver toxicity and should not be used. Atomoxetine, an inhibitor of presynaptic norepinephrine, is also less effective than stimulants but is an option for some patients.

The diagnosis of conduct disorder is made when which of the following criteria is (are) fulfilled? A repetitive and persistent patterns of behavior that violate the rights of others B stealing C lying D vandalism E a and any two of b, c, and d

E a and any two of b, c, and d The diagnosis of conduct disorder requires a repetitive and persistent pattern of behavior that violates the basic rights of others or age-appropriate rules of society, manifested by at least three of the following behaviors: stealing running away from home staying out after dark without permission lying so as to "con" people deliberately setting fires repeatedly being truant (beginning before the age of 13 years) vandalizing being cruel to animals bullying being physically aggressive forcing someone else into sexual activity Conduct disorder is a purely descriptive label for a heterogeneous group of children and adolescents. Many of these individuals also lack appropriate feelings of guilt or remorse, empathy for others, and a feeling of responsibility for their own behavior.

An 11-year-old boy is brought to the physician by his mother because of teacher complaints regarding his poor performance at school for the past 8 months. He has difficulty sustaining attention when assigned school-related tasks, does not follow the teachers' instructions, and makes careless mistakes in his homework. He often blurts out answers in class and has difficulty adhering to the rules during soccer practice. His mother reports that he is easily distracted when she speaks with him and that he often forgets his books at school. Physical examination shows no abnormalities. The patient is started on the appropriate first-line therapy. This boy is at increased risk for which of the following conditions? A Prolonged QT interval B Serotonin syndrome C Increased BMI D Abnormal liver function E Decreased perspiration F Elevated blood pressure

F Elevated blood pressure This boy is being treated with methylphenidate, which is first-line pharmacotherapy for ADHD. Methylphenidate increases sympathomimetic activity and improves concentration, cognition, and short-term memory. Common adverse sympathomimetic effects include elevated arterial blood pressure, tachycardia, sweating, insomnia, decreased seizure threshold, and a reduced appetite/stunted growth.

A 16-year-old girl is brought to the physician by her parents for her repeated behavioral problems at home and school during the past 10 months. Her teachers describe her behavior as uncooperative and disruptive as she persistently refuses to answer questions, insults her teachers, and annoys her classmates on a daily basis. At home, her parents try to address her frequent violations of curfew, but attempts at discussing the issue often result in their daughter losing her temper and screaming at her parents. Her grades have deteriorated over the past year. She has no history of psychiatric illness. On questioning, the patient refuses to answer and frequently disrupts the physician's conversation with the parents. Which of the following is the most likely diagnosis in this patient? A Reactive attachment disorder B Conduct disorder C Disruptive mood dysregulation disorder D Antisocial personality disorder E Attention-deficit hyperactivity disorder F Normal adolescent behavior G Oppositional defiant disorder

G Oppositional defiant disorder Oppositional defiant disorder (ODD) is characterized by anger, irritable mood, and defiant behavior toward authority figures and peers without serious violation of social norms, lasting ≥ 6 months. Individuals with ODD are negatively impacted in numerous areas important for normal functioning (e.g., social, educational, occupational), and the hostility they express is toward individuals within their immediate social circle (e.g., family members, peers, work colleagues, teachers), which is seen in this patient's behaviour toward her teachers and classmates. The fact that this behavior has been occurring more often than once per week goes beyond what is normative for children of her age. Furthermore, since her symptoms have been ongoing for ≥ 6 months, she fulfills the diagnostic criteria for ODD. Because the dysfunction affects individuals' social circle, peer group support and peer-mediated interventions are pivotal in treating ODD, concomitant with psychotherapy, parent management training, and social-skills programs.

An 8-year-old boy is brought to the physician by his foster mother because of complaints from his teachers regarding poor performance at school for the past 8 months. He does not listen to their instructions, often talks during class, and rarely completes his school assignments. He does not sit in his seat in the classroom and often cuts in line at the cafeteria. His foster mother reports that he runs around a lot inside the house and refuses to help his sister with chores and errands. He frequently interrupts his foster mother's conversations with others and talks excessively. She has found him trying to climb on the roof on multiple occasions. He was placed in foster care because of neglect by his biological parents 3 years ago. Physical examination shows no abnormalities. Neurologic examination shows no focal findings. Mental status examination shows a neutral affect. Which of the following is the most likely diagnosis? A Antisocial personality disorder B Autism spectrum disorder C Age-appropriate behavior D Specific learning disorder E Conduct disorder F Oppositional defiant disorder G Attention deficit hyperactivity disorder H Hearing impairment

G Attention deficit hyperactivity disorder

Which of the following would be the drug of first choice for the treatment of mild Tourette's syndrome? A Carbamazepine B Phenobarbital C Primidone D Phenytoin E Lorazepam

Lorazepam Tourette's syndrome is a genetically transmitted disorder that begins in childhood as a simple tic, progressing to multiple tics as the patient ages. Tics may begin as grunts or barks and progress to involuntary compulsive utterances called coprolalia. These outbursts may become severe and significantly disable the patient from a physical or social standpoint. Tics tend to be more complex than myoclonus but less flowing than choreic movements, from which they must be differentiated. The patient may voluntarily suppress them for seconds or minutes. Simple tics may respond to benzodiazepines. For simple and complex tics, clonidine is effective in some patients. Long-term use of clonidine does not cause TD; its limiting adverse effect is hypotension. Intermediate-acting benzodiazepines (e.g., lorazepam) may be useful as adjuvant treatment. For more severe cases, antipsychotics, such as haloperidol, olanzapine, resperidone, or pimozide, may be required. Side effects of dysphoria, parkinsonism, akathisia, and TD may limit their use. Antipsychotics should be started cautiously, and patients should be told about potential adverse outcomes.

Treatment for ADHD?

Ritalin - methylphenidate, Dexedrine - Dexamephetamine, atomoxetine clonidine, guanfacine

a 9-year-old girl who you are seeing 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. The girl is asked what has happened and what she thinks is going on but she is too shy to reply. 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.

Sexual abuse Common ages 9-12 and often by a male known to the child Any raises suspicion: Evidence of sexually transmitted infection Knowledge about sexual acts inappropriate for age Initiates sexual acts with others, peers Exhibits sexual knowledge through play TX: National Sexual Assault Hotline: 1-800-656-4673 You are required to report all cases of suspected or known child sexual abuse Prepubertal children who have no symptoms of sexually transmitted infection (STI) should not receive antibiotic prophylaxis Postpubertal children who have been sexually abused should receive antibiotic prophylaxis for STIs Victims of sexual abuse warrant assessment for hepatitis prophylaxis HIV prophylaxis - consult with a specialist in treating HIV-infected children Emergency contraception should be offered to all postpubertal female patients and should be strongly advised to females at the highest risk for pregnancy

a mother and her 6-year-old son come to the office with a concern that he continues to have nighttime wetting several times a week. He is the second child of three. He is in the first grade and struggling with his performance. He has had no medical problems. There is no history of developmental delay, and he was the product of a normal uncomplicated pregnancy and delivery. Since the birth of the third child, his behavior has been problematic. The examination of other body systems is normal. He does not have laboratory evidence of a urinary tract infection.

enuresis