623 module 6 - mental health

18. You feel that a child has experienced an early childhood adverse event. What is the best next step? a. Screen the child using the pediatric symptom checklist. b. Screen the child using an ACE questionnaire. c. Ask the family about ACEs. d. Refer the child to mental health services.

B: Using a questionnaire is superior to asking the history. Before you make any referral, you need to get more information from the family. The pediatric symptom checklist does not screen for ACEs.

2. What is the evidence-based first-line treatment for separation disorder in children and adolescents? a. Eye movement desensitization and reprocessing (EMDR) b. SSRI c. Cognitive-behavioral therapy (CBT) d. Psychodynamic psychotherapy

C: Cognitive-behavioral therapy teaches skills to change thinking and behavior so that when applied, they will help decrease anxiety.

22. TJ is a 15-year-old male with a new diagnosis of depression, and you decide to treat with fluoxetine. What are the main side effects to monitor when starting fluoxetine? a. Abnormal thinking, including suicidal ideation b. Tachycardia c. Respiratory depression

A: Fluoxetine has a black box warning for suicidal ideation. It is important to remember to screen all depressed patients for suicidal ideations, especially when they are on psychiatric medications.

7. Which of the following is true regarding the physiologic characteristics of children with panic disorder? a. At rest, children with panic disorder have increased autonomic arousal relative to healthy individuals. b. Children with panic disorder have increased autonomic arousal during panic attacks but return to normal baseline immediately following. c. Children with panic disorder have comparable autonomic arousal to healthy individuals. d. Children with panic disorder have an autonomic hypoarousal post-panic attack.

A: Rationale: The increased autonomic arousal of children diagnosed with panic disorder indicates a potential neurobiological propensity for some children to develop the disorder.

8. Which of the following statements about the prevalence of GADs is true? a. Girls are twice as likely as boys to be diagnosed with GAD. b. Girls and boys are at equal risk of having GAD. c. Boys are twice as likely as girls to be diagnosed with GAD. d. Boys have a higher rate of GAD as children, and girls have a higher rate as teenagers.

A: Rationale: The prevalence of anxiety disorders is higher in girls. It has been hypothesized that this is related to how girls use social media and how girls feel about the way they behave and look compared to other peers. Boys are generally using social media to post how they do something; girls are more likely to post how they look. This has to do with the way girls and boys are socialized.

24. What is the most common internalizing disorder of childhood? a. ADHD b. Anxiety disorder c. Depression d. Post-traumatic stress disorder

B: Anxiety disorder is the most common internalizing disorder of childhood. There may be a comorbid depression associated with anxiety, and the PNP must screen for depression starting in adolescence once a year per the AAP guidelines.

19. You are seeing a mother of a 2-year-old with biting behavior. She is biting the child back. What is the next best step? a. Tell the mother that biting the child back normalizes the behavior. b. Explore the antecedents to the behavior. c. Allow the child to spend 2 minutes in time-out. d. Encourage the mother to be very strict with the child following these biting episodes.

B: Exploring antecedents to the behavior is the next step. You can talk about the mother's choices for consequences once you determine the cause of the behavior.

23. A child has a positive Vanderbilt test by the parent, but the teacher and coach screen on Vanderbilt is negative. What is the next step? a. Follow the parental form and initiate treatment with Ritalin. b. Explore the home environment with the parent. c. Consider ODD. d. Explain the screens are not consistent with ADHD and reassure the parent.

B: Functional impairment in two or more settings is needed for the diagnosis of ADHD. It would be essential to explore changes in the home environment and to see whether the home environment lacks order. Reassurance, while helpful, needs to be done after the PNP has explored all possible reasons for the behavior.

16. A 3-year-old is described by his mother as busy. She is concerned about the diagnosis of ADHD. She denies any family history of the disease but has a friend with a daughter who has ADHD. On taking the history, the child can sit through a book, put together a shape box, and build a house with blocks. His 5- to 7-word sentences are clear and easily understandable. There is no sign of aggressive tendencies, and the child plays side by side. Based on the history, what is the next best step? a. Reassure the child's mother that 3-year-olds do not sit still. b. Ask specifics about the antecedent, the behavior, and the consequences. c. Provide a referral to psychiatry. d. Provide a referral to neurology.

B: It is essential to ask about the details of the concerning behaviors. The mother may not be easily reassured, and this is not the best approach. Showing concern by asking questions may be very helpful to elicit further information that may lead to referrals, depending on the information the PNP obtains about the behaviors.

6. You are the PNP who is performing Jack's sports physical. He is 14 years old and entering high school. He is going to try out for the football team. As he is leaving, he says to you, "If I don't make the team, I have no reason to live. It is that important to me." What would be your best first action for this statement? a. "Jack, I will have to call the crisis center. You will need to be hospitalized." b. "Tell me more about how you are feeling." c. "Oh, don't be silly; there is plenty of other things to do if you don't make the football team." d. "I am going to call your mother and tell her you to want to kill yourself."

B: Rationale: Asking the child to talk more about how he is feeling will elucidate whether these are passive ideations or whether this child is at risk for self-harm. Asking to hear more also indicates interest and validates his feelings regarding the statement he made.

11. Which of the following is helpful in distinguishing obesity from a large body frame in an adolescent who is concerned with her weight? a. Triceps skinfold b. BMI c. Weight-to-height ratios d. Percent of IBW

B: Rationale: BMI is a value of someone's weight in relation to his/her height.

10. Sherman, a 16-month-old, is brought to you by his mother. The mother is very distraught. Every day she takes him to the beach, and no matter how hard she tries to stop him, he continues to eat handfuls of sand. He has an excellent appetite and is in the 90th percentile for height and weight. She heard about a disorder called pica and that it is more common in autistic children, so she is now sure he has autism. Your best response to the mother would be: a. "You are probably correct; if he is eating sand every day, then he probably does have autism." b. "It is not unusual for 16-month-old children to explore with their mouths. Does he put other things in his mouth as well?" c. "If he is eating sand, then he must have a diet deficiency." d. "Stop taking him to the beach."

B: Rationale: Providing education regarding normal growth and development and then requesting more information will help the clinician understand the child's usual behaviors. The education will also help decrease the mother's anxiety.

12. Which of the following sets of symptoms in a school- aged child is most characteristic of depression? a. Excessive worry, somatic symptoms, fear of bodily harm b. Aggression, impulsivity, lack of empathy c. Impairment in social skills, cruelty to animals, aggression d. Irritability, loss of interest, difficulty with sleep

B: The characteristics of depression in a school-aged child vary from those in the adolescent. Choice A lists the symptoms of anxiety. Choice C should trigger thoughts of a child with a conduct disorder. It is important to identify all possible triggers and symptoms that the child is having.

20. Which of the following children is most likely to have a learning disability? a. A 9-year-old with high impulsivity, difficulty staying in her chair, difficulty completing tasks, and difficulty in maintaining friendship b. A 10-year-old who tends to score significantly higher on IQ tests than his school performance reflects c. A 10-year-old with explosive outbursts in the classroom d. A withdrawn 12-year-old with difficulty sleeping, associated with a poor appetite and lack of interest in school

B: The child with high impulsivity and difficulty with tasks and friendships is more likely to have an attention-deficit disorder, whereas the child with explosive outbursts in the classroom is more likely to have IED. A child who is withdrawn and has difficulty with sleep and appetite is likely to be depressed.

4. A 16-year-old boy is brought to the office because he has had decreasing performance in school over the past 6 months. During this time, the patient has become more irritable and irresponsible, has stopped socializing with his group of friends, and has had decreasing personal hygiene. He was previously a high-achieving student, but his grades have slipped to the extent that he is failing several courses. Which of the following disorders is the most likely cause of this patient's symptoms? a. Bipolar disorder b. D: Rationale: There is no scientific evidence that reducing refined sugars will assist a child in maintaining proper height and weight while taking psychostimulants.Conduct disorder c. Major depressive disorder d. Dysthymic disorder e. Substance use

C: Rationale: Symptoms have been present for a long enough time to meet the DSM-5 criteria for major depression. His symptoms do not meet the criteria for any other listed choice.

3. Chelsea, an 18-year-old whom you have seen for 10 years, visits the PNP to receive vaccines before leaving for college. Upon exam, you discover she is 20% below IBW. What would be your first intervention after you assess her IBW? a. Ask her for a 24-hour diet recall. b. Tell her you need to call her mother immediately. c. Review her weight and height over time as you have her medical records. d. Do nothing; lots of kids are underweight.

C: Rationale: The clinician should review the patient's weight trends before further investigating whether this is an actual problem or normal for this particular child.

9. A 13-year-old girl started junior high school in a large urban city last month, after moving with her family from the rural Midwest. She is fearful daily about going to school, afraid the other girls will make fun of her clothes and her accent. She is nauseous and unable to eat breakfast every morning and has missed at least 2 days of school in the last 4 weeks. What is the most likely diagnosis? a. Social anxiety disorder b. Normative shyness c. Adjustment disorder d. Selective mutism

C: References: The girl's symptoms have not been present long enough to meet any other diagnostic criteria for anxiety or depression.

21. What is the best first management option in a 4-year-old with signs of ADHD? a. Treat with psychostimulant. b. Wait until the child is older to do anything. c. Encourage parent- and/or teacher-administered behavior therapy. d. Encourage psychostimulants with behavior therapy.

C: The October 2019 guidelines reinforced the earlier guidelines that medication is a second-line therapy only to be used when the parent- and/or teacher-administered therapy fails to improve the behavior.

25. Which of the following sets of symptoms in a school-aged child is most characteristic of a conduct disorder? a. Irritability, loss of interest, and difficulty with sleep b. Excessive worry, somatic symptoms, and fear of bodily harm c. Aggression, impulsivity, and lack of empathy d. Impairment in social interaction, repetitive body movements, and poor communication skills

C: The presence of irritability, loss of interest, and difficulty with sleep should lead the PNP to think about depression as the underlying cause. Excessive worry, somatic symptoms, and fear of bodily harm are consistent with anxiety, whereas impairment in social interaction and poor communication skills are more consistent with ASD. The lack of empathy, aggression, and impulsivity is consistent with conduct disorder.

Questions 1. A 10-year-old girl has difficulty socializing with friends. Her mother reports that the child has difficulty visiting her friends' homes and that she often calls home to make sure her mother is fine and able to pick her up. About 3 weeks ago while visiting a friend's house, the child was shaking and sweating, vomited, and could not be comforted until her mother came to pick her up. The mother also describes that the child had difficulty going to kindergarten and would hit her mother when she tried to drop her off. The girl does not have these responses if friends come over to her house. What is the most likely diagnosis? a. Social anxiety disorder b. Dependent personality disorder c. Separation anxiety disorder d. Panic disorder

C: The symptoms described fit a separation anxiety disorder and not a panic disorder.

13. What is included in the diagnostic criteria for ASD? a. A noted lack of back-and-forth conversation b. Intolerance of flexibility in routine c. Fascination with light or movement d. Abnormal eye movements or body language

D: Rationale: Abnormal movements are not included in the DSM-5 criteria for ASD.

14. Chuck, age 8, is on a stimulant for ADHD. Which of the following interventions is the least helpful? a. Monthly height and weight checks b. Small, frequent meals and snacks c. High-calorie supplemental drinks d. Elimination of refined sugars from the diet

D: Rationale: There is no scientific evidence that reducing refined sugars will assist a child in maintaining proper height and weight while taking psychostimulants.

5. Jane is 11 years old. Her maternal grandmother died unexpectedly about 2 months ago. Since that time, Jane has refused to attend her ballet class (an activity she used to love) and cries daily. While she does go to school each day, several days each week, she has been visiting the nurse for complaints of headaches. Jane is most likely suffering from: a. GAD. b. complicated bereavement. c. major depressive disorder. d. adjustment disorder with depressed mood.

D: References: Symptoms meet the DSM-5 criteria for adjustment disorder. Her symptoms do not meet the criteria for any other listed choice.

17. A child has been to multiple specialists and has had numerous procedures done over the course of the 3 years since he was born. The child appears well. The mother is very social with all the medical staff and seems to enjoy being in the hospital. Based on current terminology, what do you think the mother's behavior reveals? a. Munchausen syndrome b. Factitious disorder by proxy c. Medical child abuse d. Factitious disorder imposed on another

D: The child's mother is showing signs of factitious disorder imposed on another. Munchausen syndrome, medical child abuse, and factitious disorder by proxy are old diagnostic terminology.

26. What are the major differences between the adolescent onset of conduct disorder and the childhood onset of conduct disorder? a. Adolescent onset is more likely to be chronic and severe. b. Adolescents with conduct disorder are less likely to be imprisoned. c. Adolescents with conduct disorder do not have normative peer relationships. d. The childhood form is more likely to be chronic and severe

D: The childhood form is more likely to be resistant to treatment and, therefore, more chronic. Adolescents are more likely to be imprisoned. Adolescents with a conduct disorder are less likely to be aggressive and more likely to have normative peer relationships.

15. A 7-month-old has an intracranial hemorrhage with a depressed fracture of the parietal bone. The parent states he fell off a bed onto the carpet 30 minutes ago. Which of the following red flags does this presentation meet? a. None; the history and physical are consistent. b. There is a delay in seeking evaluation. c. The parents failed to seek help. d. The mechanism of injury is inconsistent with physical exam findings.

D: The mechanism of injury must be consistent with the clinical presentation. Falling from a bed to a carpeted floor generally would not cause that severe of an injury.