1
Q
What are the 4 Ms for promoting healthy screen use in school-aged children + adolescents?
A
- Monitor for problematic screen use
- Complaints about being bored/unhappy without access
- Oppositional behaviour in response to screen limits
- Screen use that interferes with sleep, school, face-to-face interactions, offline play or physical activities
- Negative emotions following interactions or video games or while texting
- Model
- Review your own media habits, plan time for alternative hobbies, outdoor play and activities
- avoid screens 1h before bedtime
- Discourage recreational bedroom use
- Meaningful
- Prioritize face-to-face interaction, sleep and physical activity over screens
- Choose educational, active or social activities on screens
- Manage
- Family media plan
- Co-view and talk about content whenever possible
- Review acceptable/unacceptable behaviours proactively
- Get passwords
- Discourage multitasking during homework
2
Q
When does educational TV use peak?
When does entertainment TV + social medial take up more leisure time?
A
Preschool
By 8 years
3
Q
List 4 benefits of screen use in school-aged children
List 4 benefits of screen use in adolescents
A
School-age Benefits
- Improve academic performance → enrich knowledge + literacy skills
- Develop positive relationships with teachers and peers
- Increased math proficiency + reduced learning gaps
- Cooperative or competitive video games can offer opportunities for identify, cognitive and social development
- Increase sense of well-being, prosocial behaviour
- Lower depression risk vs no screen time if 1h/day
- help make and maintain friendships (more diverse and gender-inclusive)
Adolescents (moderate use 2-4h/d)
- Improves self-concept
- Validating
- Affirming
- Increased cognitive skills with game-specific, short-term action video games (especially in executive function and visual spatial working memory)
- Enhanced well-being
4
Q
List 4 risks of digital media in school-aged children.
List 4 risks of digital media in adolescents
A
- Poor sleep duration and quality
- Inhibit melatonin release → emotional arousal, disrupted sleep rhythms
- ↑ sedentary time + obesity risk
School-aged
- Conduct problems by 7yo if ≥3h/day at 5yo
- ↑depressive symptoms
- ↓ physical activity
- ↑exposure to harmful/negative content if not superfised
- Multitasking
- Impairs problem solving
- Undermines confidence in ability to do homework
- Disrupts reading efficacy
- Being economically disadvantaged or minority/marginalized is associated with more media use
Adolescent
- No use or excessive use → feelings of alienation and social exclusion
- Depression risks
- Receiving negative content in instant messages (also anxiety)
- Excessive use (>6h/d)
- Passively surfing internet when one has few or no close friends
- Lower English + math scores
- Weaker working memory
- Lower sustained attention
- Greater impulsivity
- If >50% free time is spent on gaming → hyperactivity, conduct problems, peer issues and emotional problems
*
5
Q
What approach should you use to strength relationships with and within families you see.
List 2 ways to increase family engagement and build trust
A
- Ask questions
- Build on family’s relational strenghts
- Counsel with family-centred guidance
- Develop plans for changing behaviours related to sleep or discipline PRN
- Educate about positive parenting strategies
Engagement
- Ask parent about their childhood (“how did your parents help you deal with emotions”)
- Screen relational issues/social isolation (“who do you turn to for support”)
- Motivational interviewing
- Reframe negative exchanges (“I wonder if there’s a more helpful way to think about this behaviour”)
6
Q
What are the issues that parents most often seek advice from health care providers regarding?
A
7
Q
How should parents approach disciplining their children?
A
- ‘Positive discipline’
- Teaches child appropriate behaviour rather than punishing them for inappropriate behaviour
- Uses “I statements” “ I don’t like it when you do that”
- Purpose: foster independence and communication skills, problem solve, take responsibility for behaviour
Be consistent without being rigid
Wait until both child and parent are emotionally ready to re-engage
“Redirect”
- Reduce words
- Embrace emotions
- Describe (without lecturing)
- Involve the child in discipline
- Reframe a ‘no’ into a ‘yes’ (with conditions)
- Emphasize the positive
- Creatively approach a disciplinary situation
- Teach
8
Q
When does a baby develop normal circadian rhythm cycle?
List 3 healthy strategies to promote self-soothing at bedtime for babies
What should be the first line strategy to prevent sleep problems in infants and young children?
A
At least 6 months of age
- Consistent, calming sleep routines (“bath, book, bed”)
- Settling babies into their cribs drowsy, but still awake
- Putting babies to bed without a bottle
- Waiting a few minutes to see if they settle to sleep on their own after waking
- Avoiding overstimulation during night-time feeds or diaper changes
Gradually withdraw parental attention while maintaining a presence at bedtime (lying near but not interacting with children until they fall asleep) or leaving room and not returning for 2-5 minutes before responding to crying, then lengthening that interval
9
Q
How can paediatricians help parents with problem behaviours? What approach should you take?
A
ABCs
- Antecedants (what events precede the behaviour and how are parents responding)
- Time-ins: Connect then redirect
- Behaviours
- Consequences
Environmental factors (may be contributing to stress but can be modifiable): living conditions, transitions, scheduling, possible interferences
Serious, disruptive or intractable child behaviours - early clinical recognition, connect with evidence-based Parent Management Training program
10
Q
Provide guidance regarding crying behaviours for a mother that has a baby with infantile colic
A
- Crying is a form of communication - how they call for help, physical closeness or to have their basic needs met
- Responding consistently, quickly and warmly helps develop secure attachment
- Episodes become shorter when parents learn to anticipate and respond to early cues
- Cannot “spoil” an infant with warmth and comforting
- Parents need regular social/emotional support
- Feelings of frustration are normal
- If feeling overwhelmed, stress or exhausted, take regular brief breaks or ask partner, trusted family member or frient to some child care
- Share evidence-based informaiton on soothing strategies
11
Q
List 2 protective parenting factors
A
- Consistent care provider
- Healthy routines
- Being read to
- Using community resources
- Parent’s social network
- Positive work-life balance
- Limited family screen time
- Healthy bedtime routine
12
Q
Which car seat should be used for which patients?
When can you stop using car seats?
A
Car seat A = forward facing seat (full restraint)
- for ages 1-4
Car seat B = booster seat with back
- for ages 4-8
- must use booster with back if seat in car has no headrest
Car seat C = booster without back
- for ages 4-8, if seat has headrest
Criteria to stop:
- age at least 8
- OR 145 cm
- OR 36 kg
13
Q
What are the facial features of FASD? What are the common developmental issues?
A
- Common issues:
- Cognitive and learning disorders
- ADHD (severe and refractory)
- Poor judgement, poor sense of cause and effect
- No known safe amount of alcohol
- Physical exam features: midface hypoplasia, small palpebral fissures, epicanthal folds, flat midface, thin upper lip, smooth philtrum
- But rare to have facies
14
Q
1) Baby can transfer a rattle hand-to-hand, sit with a rounded back using hands for support. What is his age: 1. 3 months 2. 4 months 3. 6 months 4. 9 months 5. 12 months
A
- 6 months -most primitive reflexes gone, sits in tripod, shakes rattle, holds cube with 2 hands, vocalizes to give answers, bangs cubes together
15
Q
2) An infant can sit with a round back using his hands for support, can roll from prone to supine, stands with support, has a palmar grasp, laughs, and babbles. a) 3 months b) 6 months c) 8 months d) 9 months e) 12 months
A
b) 6 months
16
Q
3) What is true of a normal 9 month old child? 1. just acquired palmar grasp 2. says mama/dada and one other word 3. has object permanence 4. has names for objects
A
- has object permanence Major milestone achieved by 9 months
17
Q
4) A 10 month old child bites you. Which statement is true? a) This is an early sign of possible autism spectrum disorder b) There may be an abusive situation in the family c) Baby is developmentally normal and he is excited
A
c) Baby is developmentally normal and he is excited Everything goes into the mouth at 6 months; lots of kids bite during play
18
Q
5) Which is the most characteristic of a 9-12 month old? a. object permanence b. imitates scribbling c. transfers objects from hand to hand d. uses mama and dada specifically
A
ANSWER: d. uses mama and dada specifically a. object permanence - have by 9 months b. imitates scribbling - 18 months c. transfers objects from hand to hand - starts at 6 months
19
Q
6) All of the following are true about development EXCEPT: a) walk 3 steps at 15 months b) copy horizontal line at 15 months c) stack 3 blocks at 18 months d) speak 10 words at 18 months e) climb stairs holding rail at 18 months
A
ANSWER: b) copy horizontal line at 15 months - “makes line with a crayon” at 15 months, but “imitates vertical stroke at 18 months and horizontal stroke at 24 months” a) walk 3 steps at 15 months - yes, should walk alone by 15 months c) stack 3 blocks at 18 months - yes, should do this at 15 months d) speak 10 words at 18 months e) climb stairs holding rail at 18 months - yes, climbs stairs with one hand held
20
Q
7) A picture of child showing the parachute reflex is shown. What is true? a) This is a primitive reflex that disappears by 4 months b) This is a voluntary reflex which disappears when child starts walking c) This is an involuntary reflex that appears at 7-9 months and does not disappear
A
c) This is an involuntary reflex that appears at 7-9 months and does not disappear Need parachute reflex to start walking so if you fall you don’t smash your face; it doesn’t go away (so you keep not face smashing)
21
Q
8) Which is the indication for urgent evaluation? a. Baby does not turn to sound at 4 month b. Baby no babble at 6 mo c. 15 mo does not follow simple command without gesture d. 24 m without 2 word phrases
A
ANSWER: a. Baby does not turn to sound at 4 month b. Baby no babble at 6 mo - should babble at 6 months, but not red flag if not c. 15 mo does not follow simple command without gesture - 12 months should follow 1 step command with gesture, 14 months should follow 1 step command without gesture d. 24 m without 2 word phrases - should have 2 word phrases at 2 years
22
Q
70) A child is seen with her mother. The child reportedly wakes to loud noises. She stops crying when comforted by her mother. She makes some cooing and gurgling noises and is feeding well. When prone she is able to lift her head off the surface. When she is held up against her mother’s shoulder she lifts her head off the shoulder. She is not yet putting weight on her forearms when in prone. She is not yet holding her head steady when in a sitting position. The developmental age of the child is: a) 2 weeks b) 4 weeks c) 6 weeks d) 8 weeks e) 10 weeks f) 12 week= Nelson’s 3 mon= life head with arm extended, waves at toys, head lag partially compensated, moro gone, sustained eye contact and says “aah, ngah”
A
ANSWER: d) 8 weeks= Nelsons= raises head sustained on ventral suspension, head lag when pull to sitting, follow objects, smile with contact, listen to voice + coo f) 12 week= 3 mon= lift head with arm extended, waves at toys, head lag partially compensated, moro gone, sustained eye contact and says “aah, ngah”
23
Q
69) A little boy is brought in by his father. He responds to having his name called, smiles and babbles when you speak with him. He squeals with delight when bounced on his father’s knee. He grabs at a toy and puts the toy to his mouth When in prone he is able to push up on his hands and hold his head steady. He then rolls onto his back. In a sitting position he leans forward and puts some weight on his hands. He not yet sitting unsupported. He is not picking up small items with thumb and first finger. The developmental stage is: a) 2 months b) 4 months c) 6 months d) 8 months e) 9 months
A
c) 6 months
24
Q
73) A child visits your office with her mother. She brings a doll and her purse with her. She asks her mother “where is my cookie?”. She tells you “I went to Allison’s birthday party. I wore my pink Sleeping Beauty dress, we had a fashion show and we made a wand craft. I am having a Dora birthday and all my friends are coming.” Her party is in 2 days. She easily imitates drawing a circle and cross, but has trouble with a square. She is happy to pretend to examine her doll with your stethoscope while you talk to her mother. How hold will this child be at her birthday party? a) 3 years b) 4 years c) 5 years d) 6 years
A
b) 4 years = at least 3 given circle, cross but not quite 4 y.o. milestones so next birthday party is
25
72) The average 2 year old has the following developmental milestones? a) Vocabulary of 100 words b) Speaks in 2 word sentences c) Follow 2 step commands d) Clear articulation e) 1 and 2
e) 1 and 2 a) Vocabulary of 100 words= YES should have by 18-24 month b) Speaks in 2 word sentences = YES should have by 18-24 month c) Follow 2 step commands= attained usually between 24-36 month d) Clear articulation -\> 90% in 4 y.o. and 100% in 5 y.o. e) 1 and 2
26
68) A girl comes to your office, she walks into the room independently and squats to pick up a ball and follows the direction “throw me the ball” when you ask. She says dada and mama for dad and mom and baba for bottle and says “all gone” or “uh oh” in the exam room. When asked “where is your nose, eyes and head” she points appropriately. She points to a ball and says “ba”. She says “mo” to request more cheerios. She makes good eye contact. She stack 3 small blocks. When she leaves the exam room she waves bye-bye. What is her developmental age? a) 10 months b) 12 months c) 15 months d) 18 months e) 20 months
d) 18 months -Gross Motor: walk (12 mon), squats (\< 2y.o.) -Fine Motor: throws (min. 12 months), 3 tower (min. 12 month since agex3= # cubes in tower) -Speech: specific mama and dada (12 month minimum), points (15 month), follow simple command (15 months). Not quite 2-3 word phrases = 2 y.o. -Social: knows body parts (18 month),
27
71) Which milestone do most children achieve first? a) Overhand throw of a ball b) Kicking a ball c) Hopping d) Riding a tricycle e) Skipping
b) Kicking a ball (18 month) a) Overhand throw of a ball (2 y.o.) b) Kicking a ball (18 month) c) Hopping (4 y.o. hops on one foot) d) Riding a tricycle (5 y.o.) e) Skipping ( 5 y.o.)
28
93) Who to refer to SLP? a. 6 year old with trouble with phonemes b. no words by 18 months, in a bilingual household c. 2 year old, people only understand 50%
b. no words by 18 months, in a bilingual household refer to SLP if: not using 3 words at 15 months
29
102) Delayed 4 y/o. Can go up and down stairs one foot at a time. Three word sentences. Vertical lines, no circle. 50 words. What is his developmental age. a. 18 b. 24 c. 30 d. 36
c. 30 Vertical line at 18 months, circle at 3 years, 3 word sentence at 2-3 years, alternating feet on stairs at 3 years
30
Name 1 milestone in each of the following criteria for a 36 month old: 1 line each a) gross motor b) fine motor c) language d) social
a) gross motor – tricycle, stairs alternating feet, stands on one foot briefly b) fine motor – 9 block tower, circle, uses utensils, undresses c) language – 3 word sentences, 250 words, 75% intelligible d) social- group play, shares, knows name and age
31
Write “normal” or “abnormal” for an 18-month old child that you are assessing in your office? Has 2 words Walked at 14 months and is unable to go up and down stairs Doesnʼt point to things Displayed a hand preference at 10 months of age
Has 2 words – abnormal (should have 7-20) Walked at 14 months and is unable to go up and down stairs - normal Doesnʼt point to things - abnormal Displayed a hand preference at 10 months of age – abnormal
32
Kid is 10 months old, ex 28 weeker. What is developmental age. Sitting independently for 10 min, could roll over, not yet cruising, no pincher grasp. Babbled. Not pulling to stand. Look for dropped objects briefly.
Sitting independently for 10 min (6-8m) , could roll over ( 6-8mo) , not yet cruising ( 9-11m) , no pincher grasp (9-11m). Babbled (6-8mo). Not pulling to stand (9-11). Look for dropped objects briefly. (9-11m) - cGA 7 months, developmental age 6-8m
33
Child who is 2 years old. Speaks 8 words. Points and gestures. Socially appropriate. What is the most likely diagnosis: 1. Global developmental delay 2. Developmental language disorder 3. PDD
2. Developmental language disorder
34
A 3 year old child is seen in your office. He just started making 2 word sentences and has about a 50 word vocabulary. His receptive language is better than his expressive language. He can build a tower of 12 blocks and make a very nice house out of Legos. What do you counsel the mother that he is at risk for in the future: a. Autistic spectrum disorder b. Developmental disorder c. Reading disorder d. ADHD
c. Reading disorder (yes! strong association (50%) between language disorder and later reading disorder)
35
A mother is concerned that her 3-year-old child was able to speak 3-4 words sentences at 22 months of age but now she seems to be stammering/having dysfluency of speech a lot. What next: a) reassure b) audiology testing c) refer to speech pathologist d) complete neurodevelopmental assessment e) emotional disturbance can be the cause of stammering
a) reassure - developmental disfluency - common between 2-3 years, lasts weeks to months and resolves by age 4 without treatment; child is not frustrated or distressed versus stuttering they are If they specifically were talking about stuttering, usually onsets between 4-5 years, multiple repetititions common (more severe than dysfluency), and needs referral to SLP (of note, can be caused/worsened by emotional disturbance)
36
7 yo boy with past history of speech delay. His reading is now below a grade 1 level. Teacher thinks that he has ADD. What would be the most appropriate next step: a) investigate for learning disability b) psychotherapy c) behavior therapy d) Ritalin 5mg bid e) Ritalin 20 mg bid
a) investigate for learning disability Early language disorder is strongly associated with reading disorder
37
In a child with expressive speech delay, the parents should be encouraged to all of the following except: a) read to him at night b) make him repeat incorrectly pronounced words over and over c) make him stop his activity and look at you when you talk d) don’t complete his sentences
b) make him repeat incorrectly pronounced words over and over
38
A 2 year old boy has only 3 single words, he has poor receptive language, does not point to indicate his wants, does not orient to his own name and does not engage in pretend play. He loves to play with his blocks. Which of the following is important in your investigation of his problem: a. Psychological assessment b. MRI head c. Speech/language assessment d. Audiology testing
d. Audiology testing Sounds like autism, but always need to rule out hearing impairment
39
You are seeing a 3 year old girl for language delay. While her mother is talking she wanders around your exam room. She says ‘go out’ to her mother. She puts her mothers hand on a toy to get her to fix it. She does not respond when you call her name. Of the following history items, which would assist you to make your diagnosis? a) Recent family stressors b) Family history of delayed language c) Description of her social interactions with family and children at daycare d) Resuscitation history after birth
c) Description of her social interactions with family and children at daycare She be autistic
40
2½-year-old child is referred with language delay and inferior ectopia lentis. You should a) molecular studies for Marfan syndrome b) echocardiogram to rule out aortic root abnormalities c) fibroblasts/skin biopsy for enzyme assays d) quantitative serum amino acids e) platelet count and coagulation studies for hypercoagulability
d) quantitative serum amino acids homocystinuria: mitral valve prolapse, tall stature, long bone overgrowth, developmental delay diagnosis: elevated methionine or homocystine in body fluids (including blood and urine) are diagnostic, cystine is low or absent in plasma - can do liver biopsy to look for the enzyme
41
All of the following are true of vision in newborn infants EXCEPT: a) should be able to fix on a large object from birth b) by 2 months of age the infant can follow through 180 degrees c) retinal hemorrhages are rare in newborns and cause permanent deficits d) a newborn’s sclera is thin which causes a blue hue
c) retinal hemorrhages are rare in newborns and cause permanent deficits - superficial retinal hemorrhages may be observed in many newborn infants - the majority resolve within 2 weeks - complete resolution of all birth related hemorrhages expected between 4-6 weeks
42
Which is true regarding children in foster care: 1. In older kids, occasional visits with parents is warranted if child previously had developed a strong attachment to parents 2. Disruption of continuity of care may be potentially detrimental to all children 3. If they are in a loving foster home for their first year of life, they will do well long term 4. Child should be placed with grandparents for best long-term outcome
2. Disruption of continuity of care may be potentially detrimental to all children unpredictable contact with parents, and placement changes negatively impact child's health
43
1-year-old child with psychosocial deprivation. Which is the most likely finding: a) poor appetite b) parental history of inadequate caloric intake c) microcephaly d) normal development e) absence of cuddling response
a) poor appetite - per Alli
44
A mother of a 9 yo boy visits you in your office. She would like to know what the effects of her separation and impending divorce will have on her son. The statement that you are most likely to include in your discussion with her would be: a) If the mother and son undergo psychological counselling the effects of the separation and divorce will likely be short-lived. b) Males adjust better than females in the immediate period after divorce. c) Joint custody is better for the child regardless of whether there is continued conflict between the parents. d) Parental depression and conflict issues will more likely determine the adjustment of the child than custody issues. e) The most important issue to address at this time is custody.
d) Parental depression and conflict issues will more likely determine the adjustment of the child than custody issues. 3 most significant factors impacting child’s well being during a divorce: - quality of parenting - quality of parent-child interaction - degree, frequency, intensity and duration of hostile conflict
45
Of the following behavioral phenotypes, which describes Williams Syndrome (7q11.23 deletion)? a) Strengths in verbal short term memory, extreme weakness in visual-spacial skills, excessive talking, hyperacusis, inattention, phobias and sleep problems b) Depression, shyness, social anxiety, executive function deficits, cognitive decline and dysinhibition c) Delays in motor and language skills, mild cognitive impairments or learning disabilities, and obsessive compulsive characteristics d) Severe cognitive impairments, minimal verbal communication, movement or balance disorder, easily excitable
a) Strengths in verbal short term memory, extreme weakness in visual-spacial skills, excessive talking, hyperacusis, inattention, phobias and sleep problems NOTE: c) Delays in motor and language skills, mild cognitive impairments or learning disabilities, and obsessive compulsive characteristics (Usually more ADHD, GAD)
46
You are seeing an 18 month old boy with Fragile X syndrome. Which of the following developmental issues would not be seen in boys with a full FMR mutation? a) Delays in fine and gross motor skills b) Relatively strong expressive communication c) Cognitive impairments d) Hyperactivity and distractibility e) Social avoidance and anxiety
b) Relatively strong expressive communication (usually delayed speech by 2y.o.)
47
You are seeing a 3 year old boy with his foster parents. There is a confirmed history of prenatal alcohol consumption. Which of the following physical findings would support a diagnosis of FAS? a) Weight at 50 th percentile b) Height at 50 th percentile c) Philtrum length at \<3 rd percentile d) Palpebral fissure length \<3 rd percentile e) Head circumference at 25 th percentile
d) Palpebral fissure length \<3 rd percentile
48
Of the following syndromes with tall stature, which does not have MR as part of the presentation? a) Fragile X b) Sotos Syndrome c) Karyotype XYY d) Marfan’s Syndrome e) Homocysteinuria
d) Marfan’s Syndrome Karyotype XYY: (Jacob’s tall and possible LD and behavioural/aggression; and extra note: XXY- tall stature called Klinefelter also at risk for LD)
49
What syndromes are on the differential diagnosis for a child with tall stature and developmental of behavioural abnormalities?
Klinefelter, fragile X, homocysteinuria, Loeys-Dietz, Sotos, Weaver syndrome
50
What's the syndrome? ● Tall stature, Gynecostmastia, delayed puberty, infertility, small firm testes, high pitched voice, LD
Klinefelter (XXY)
51
What's the syndrome? Tall stature, ● large head, long thin face with receding hairline ● feeding difficulty since birth with facial flushing and hypotonia. ● High palate and pointy chin
Sotos syndrome (5q35 deletion)
52
What's the syndrome? ● marfan-like habitus, developmental delay, inferior subluxation of lens , cataracts, crowding of teeth
Homocysteinuria
53
You are asked to consult on a newborn with congenital anomalies. The child has a coloboma of the iris, TOF, choanal atresia, dysplastic low set ears. The pregnancy and family history are unremarkable. The karyotype is normal and FISH for microdeletion of 22q11 is negative. What is the most likely diagnosis? a) Cornelia de Lange b) Williams Syndrome c) Noonan Syndrome d) Vater association e) CHARGE syndrome
e) CHARGE syndrome - AD genetic disorder, usually no fhx ● Coloboma (hole in structure of eye: iris, retina, choroid disc etc.) ● Heart Defects (including conotruncal like TOF), AV canal defect, aortic arch abnormalities ● Atresia Choanae (unilateral or bilateral) ● Retardation of growth/development (DD, short stature) ● Genital/urinary abnormalities (micropenis, cryptorchidism, hypoplastic labia, delayed puberty) ● Ear abnormalities and deafness (asymmetric, reduced height, cup shaped etc.) Note major criteria are different than acronym - coloboma, choanal atresia, cranial nerve anomalies, ear anomalies
54
How is CHARGE syndrome diagnosed?
Clinical criteria (all 4 major or 3 major and 3 minor); genetic testing - molecular testing
55
A 3 mo baby with wt. 6.3kg, length normal, hc 47cm. What initial investigation would you do?
Head U/S
56
4 biologic determinants of child development
- genetics - in utero exposure to teratogens (mercury, alcohol) - low birth weight - postnatal illness/ insults (meningitis, TBI, chronic illness)
57
Which of the following interventions would be provided by an Early Childhood Resource Specialist? a) Design home or school based activities to practice speech and language skills b) Provide consultation to parents regarding behavioral concerns and parenting strategies for children with special needs c) Develop augmentative communications tools d) Focus on sensory environment to achieve functional daily tasks e) Provide information on positioning and handling
b) Provide consultation to parents regarding behavioral concerns and parenting strategies for children with special needs
58
You are working in an international adoption clinic. A family brings you a file on a potential adoptee. Which of the following is most likely to correlate with a poor outcome: a. Microcephaly proportional to height and weight delay b. Developmental delay proportional to height delay c. Microcephaly with normal height and weight parameters
a. Microcephaly proportional to height and weight delay - to me more suggestive of malnutrition, which could be reversible b. Developmental delay proportional to height delay c. Microcephaly with normal height and weight parameters - more suggestive to me of underlying syndrome/early exposure that will not be reversible - peds in review 2004 - preparing families for international adoption (red flags: IUGR, microcephaly out of proportion to other growth parameters, FAS facies)
59
2.5 year old child who is not combining 2-words, has about a 50-word vocabulary and other people understand about 25%. Otherwise, climbs stairs, runs around, throws underhand. Interested in other people. What is this most consistent with? a . isolated language delay b. global developmental delay c. autism
a . isolated language delay
60
An 18 month old child in your office with the concern of developmental delay. He is babbling but does not yet say mama and dada or any other words. He is able to sit unsupported for a brief period of time. He does not yet have a pincer grasp a. What is her developmental age? b. He has a 13 year old brother in “special education” classes and a maternal cousin with autism. What one test would you want to do and why (2 lines)?
A) 6 months Babbling: 6-8 months Mama/dada: 9 months Other words: 12 months Sit unsupported briefly: 6 months Pincer grasp: 9 months B) fragile X - male child with global delay, has a brother similarly affected and fragile X is X-linked and would come from mother - notable that there is another affected relative on mom's side; fragile X can present like autism
61
A 3 y/o girl with regression of milestones is noted to have microcephaly. What is the most likely diagnosis: 1. Childhood disintegrative disorder 2. Autism 3. Rett's 4. Fragile X 5. TORCH infection
3. Rett's 1. Childhood disintegrative disorder - removed from DSM 5, not associated with microcephaly; now part of autism spectrum disorder 4. Fragile X - accounts for 3% of males with intellectual disability, females have less severe disease, no regression
62
You are seeing a 2 year old girl in whom you have told the family that you are suspicious of autism. The mother has been doing some research and asks you questions about Rett syndrome. Name 4 features of Rett Syndrome.
- normal prenatal/perinatal course - normal development until at least 6 months - regression of previously acquired milestones (especially language and social) - acquired microcephaly - repetitive hand wringing movements
63
Most predictive of mild MR? a. Maternal alcohol during pregnancy b. Cocaine during pregnancy c. Mom did not finish high school d. Neonatal hypoxia
c. Mom did not finish high school
64
Mother used IV heroin before and during her pregnancy. Her 10 month old child is now losing acquired milestones and developing bilateral spasticity. The most likely cause is: a. HIV b. CMV c. cerebral palsy d. syphilis
a. HIV CNS HIV: variable - mild developmental delay to progressive encephalopathy with loss or plateau of milestones, cognitive deterioration, impaired brain growth leading to acquired microcephaly and symmetric motor dysfunction - spasticity, hyperreflexia and gait disturbance can occur Re: syphilis: babies with congenital neurosyphilis may have seizures, but otherwise wouldn’t present this way
65
You are seeing a 9 month old in your office. She is babbling and understands the command “no”. She cries when you take her away from her mother. She rolls but does not sit. She picks up a small object with an immature pincer grasp. What do you say to her mother about her development? a) Her development is normal b) She has delays in her language skills c) She has delays in her social skills d) She has delays in her gross motor skills e) She has delays in her fine motor skills
d) She has delays in her gross motor skills
66
A 4 year old comes to your office with the concern of developmental delay. He can say his full name, age, and sex, as well as count to 3 and name 3 body parts. He can ride a trike and stand briefly on one foot. He helps to undress himself and plays pretend games with other children. He can copy a circle and a cross. What is his developmental age: a. 24 months b. 36 months c. 48 months d. 60 months
b. 36 months
67
Developmental concerns associated with neonatal risk factors, motor delays, genetic conditions are typically identified early, often by primary physicians. Milder, often very common, developmental concerns are often not identified until later in childhood or upon school entry. Which of the following conditions is more likely to be identified in a school aged child rather than a younger child? a) Learning disability b) Mild cognitive issues (mild MR, borderline cognitive abilities) c) Aspergers syndrome d) 1 and 3 e) All of the above
e) All of the above
68
You are seeing a 10 year old boy with a previous diagnosis of MR. He is not dysmorphic and his growth parameters are at the 50 th percentile. He functions like a 5-6 year old. He did have a genetic work up which as all normal. His mother wonders if the cord wrapped around his neck at birth was the cause of his cognitive impairments. He needed minimal resuscitation. What do you say to her? a) An etiology is commonly found for children with MR b) He needs more testing to answer her question c) He should have an MRI to delineate the etiology of the MR d) It is unlikely that the delivery was the cause of his cognitive impairments e) His diagnosis needs to be reviewed
d) It is unlikely that the delivery was the cause of his cognitive impairments o Mild: IQ 50-70= mental age as adult near 9-11 y.o. ▪ more environmental; identifiable cause in \< 50% ▪ If biocause: genetic or chromosomal (Williams, Noonans), IUGR, prem, prenatal exposure (FAS) o Severe: IQ \< 50= mental age as adult near 3-5 y.o. ▪ identified cause in \> 75% ▪ Chromosomal: T21, Wolf-Hirschhorn Syndrome ▪ Genetic and Other: Fragile X, Rett Syndrome, Angelman, Prader-Willi ▪ Abnormal brain: example lissencephaly ▪ Inborn errors of metabolism or other neurodegenerative
69
Which of the following is a sign of Aspergers: 1. Gross motor delay 2. Preserved language development 3. Adequate social skills 4. Fine motor delay
2. Preserved language development
70
You are asked to assess a child for autism. Which of the following statements would best support the diagnosis? a) child takes toys from other children in the examining room b) child consistently displays a startle response to a ringing telephone c) child spends much of the examination spinning a wheel on a toy truck d) child brings each of the toys into the exam room to show his mother
c) child spends much of the examination spinning a wheel on a toy truck Autism diagnosis: persistent impairment in social communication and interaction + restricted repetitive pattern of behavior/interest
71
What are the 2 core criteria of autism diagnosis and an example of each?
1. impairment in social communication and interaction - deficits in developing/maintaining relationships; deficits in non verbal behaviours; deficits in socio-emotional reciprocity 2. restrictive, repetitive behaviours or interests - stereotypies (echolalia, hand flapping, spinning) - inflexibility/strict demand for routine - restricted fixated interests - hyper/hyporeactivity to sensory inputs
72
A mother has a 2 year old child recently diagnosed with autism. Mother is currently pregnant with her second child and wants to know the risk of this child also having autism. What do you tell her about the recurrence risk? a. It is lowered if she does not give the MMR vaccine b. There is no difference from the population risk c. There is a slightly increased risk over the general population
c. There is a slightly increased risk over the general population ● RF: male o FHX: high recurrence risk in siblings (2-19%) o Closer spacing of pregnancies o Advanced maternal or paternal age o Extreme prem birth (\< 26 wk GA) o FHX (+) for LD, psychiatric dx or social disability
73
15 month who only says “ma”, stereotypical play, does not engage in social play. What is the best predictor of autism? a. Hyperactivity b. Hand flapping c. Does not point to things to show interest d. Preserved language development
c. Does not point to things to show interest
74
3 year old male talking at a 1.5 year level. No echolalia. Plays normally. Comprehension better than expression. Motor development normal. What is he at risk for a. PDD b. Developmental Disorder
b. Developmental Disorder (abnormal pattern of development) - seems at risk for language disorder (PDD = autism)
75
A 4 yo child with symptoms of autism. What is the diagnosis (1). What 2 neurologic disorders are associated with this.
1) Autism 2) Tuberous Sclerosis and Neurofibromatosis (Angleman, Rett, Fragile X)
76
Description of a child with florid autism. Name 3 tests you should order. Which 2 consultants or services would you involve to help you with your diagnosis?
1 ) Hearing Test, Microarray, Fragile X 2) Developmental Pediatrician, Speech and Language Therapist
77
List 4 diagnostic features of autism.
- Impairment in social communication and social interaction - Restrictive and repetitive behaviours/ interests - Presence in early developmental period - Significant impairment in social occupational or other area of functioning
78
A mother brings her 1-year-old child for concern regarding head banging. Physical exam is normal. The parents are worried about brain damage. What should you do: a) reassure b) EEG c) CT head d) use a helmet to prevent head injury e) family psychological assessment
a) reassure - typically begin in the 3 years of life, often before age 2 years - in typically developing children the movements resolve over time - specifically self-injurious behaviours like head banging occur in up to 25% of toddlers but in kids over 5 are almost always associated with developmental disorders - Developmentally Normal child unlikley to hurt themselves from injury
79
Parents bring their 18 month old son to see you because of concern about head banging. What treatment, if any, do you offer (1)?
Reassure- cannot cause brain/skull injury (in normally developing children) and usually grow out of it ▪ Mild- ignore the behavior, encourage substitute behavior and do not convey worry to child ● May disappear with time and elimination of attention
80
Mom has son with aggressive behaviors. You want to start risperidol. What 3 SERIOUS side affects will you tell mom about drug
EPS, Prolonged QT, NMS
81
Child 3 y/o referred for behaviour problems. Mom concerned because child refuses to wear patch for amblyopia for the past 8 months. What do you do? 1. Refer to social work 2. Immediate referral to ophthalmology for other treatment modalities 3. Refer to ophthalmology once child has started to wear patch again 4. Refer to parenting class through public health to learn skills to make child wear patch
2. Immediate referral to ophthalmology for other treatment modalities
82
Marital troubles at home, child is acting out at school and daycare. Mom has come in for advice. a. give the mom parenting classes b. request a meeting with both parents to assess the home situation. c. give him Ritalin
b. request a meeting with both parents to assess the home situation.
83
Divorcing parents. What’s best for the kid? a. best if joint custody could be given asap b. best if child gets to see both parents (i.e. joint custody) even if the parents are fighting all the time c. best if parents can settle their differences and not fight in front of kids
c. best if parents can settle their differences and not fight in front of kids
84
10 year old boy who has recently been made aware that his teenage brother is dying of ALL. He spends all his time out with his friends and is not wanting to be with the family. Mother concerned - what do you tell her?
- Death of family member is most difficult loss for a child - Reluctant to talk because adults around them are uncomfortable to talk - Turn to peers and tell adults they don’t want or need to talk about it - Presence of secure and stable adults to meet needs and permit discussion about the loss is most important o No single way to grieve- respect difference and reach out to support each other o Maintain emotional/ physical presence (hug, talk, ask)
85
A 13 y/o boy starts fires, school problems, hurts pets, threatened a child at school with a knife. What is his likely diagnosis? 1. ODD 2. Conduct Disorder 3. ADHD
2. Conduct Disorder
86
9 year old boy who has killed a cat in the last year and set fires to property. He has also been caught stealing and is aggressive at school. What is his diagnosis? a. oppositional defiant disorder b. conduct disorder c. ADHD d. Antisocial personality disorder
b. conduct disorder
87
You see a 7 year old child with the concern of thumb-sucking. Which of the following is important to include in the discussion of the risks and benefits of intervention in this patient: a) Thumb-sucking never causes self-esteem issues b) Thumb-sucking can lead to dental malocclusion and facial growth abnormalities c) Topical deterrents are very effective
b) Thumb-sucking can lead to dental malocclusion and facial growth abnormalities - thumb sucking beyond 5 years can be associated with paronychia (red, tender bacterial or fungal infection at base of nail) and anterior open bite (gap between upper and lower front teeth)
88
A 4 yo sucks her thumb while watching TV. What to tell mom? a. Put a bitter tasting substance on her thumbs b. Reassure c. Prescribe a mouth appliance d. Reward system
d. Reward system - mgmt: ignore thumb sucking; praise child for alternate behaviours - reminders and reinforcement (sticker for each block of time with no thumb sucking)
89
A 30 month old child with temper tantrums starting after the onset of attempting toilet training. What to do: 1. Time outs 2. Persevere 3. Take a 1-3 month break from toilet training 4. Reward with stickers each time on the potty
3. Take a 1-3 month break from toilet training
90
2 yo with temper tantrums. Give advice to mom x2
- tantrums are common in this age group, triggered by anger/feeling overwhelmed and more likely if child is tired or hungry - put in time out at early signs of tantrum to prevent escalation -\*\*\*positive reinforcement for times when they are tantrum free
91
20 month old child. Each time the parents say "no" child cries, turns blue and then passes out with some generalized tonic clonic movements. He recovers within 1 minute and the parents administer CPR. What do you recommend? 1. Consistent discipline 2. do not upset the child
1. Consistent discipline Breath holding spells - common in 6-18 months, can occur until age 5 ● Tx: try to intercede before child highly distressed (time out, parent model anger control you want child to show) ● Tx: ignore behavior when start
92
An 8 month old baby is not sleeping through the night. She is waking up one hour after being put down in her crib. Which of the following is true: a) this should improve if she learns to fall asleep in her crib vs. being rocked to sleep b) she should be allowed to cry to sleep to solve this problem c) giving the baby a pacifier is a proven technique d) she should be given a bottle of warm milk to help her fall asleep in her crib
a) this should improve if she learns to fall asleep in her crib vs. being rocked to sleep
93
At what age should a child be able to self-soothe when he awakens at night? a. 5-7 months b. 8-10 months c. 11-13 months d. 14-17 months
c. 11-13 months (most should be able to by ~12 months)
94
You are referred a 15 year old boy with a history of fatigue. On history you find that he is going to bed very late and having to get up very early for school each morning. There is nothing else concerning on history. What are five recommendations you make to him and mother regarding sleep hygiene?
- Quiet and comfortable sleep environment - dim lights, calm environment - Consistent bed and waking time - Avoid stimulation (Tv, computers, video games within 1-2 hours of bed time) - avoid caffeine after mid-afternoon - no smoking, alcohol, herbal remedies for sleep - Read a book (not tablet) to mentally fatigue - Increase physical activity in daytime (but not within two hours of bedtime) - Limit bed use to sleep (not for tv, eating, homework)
95
A father comes to you because his 4 year old child has been awakening every night for the past 2 months; he and the child’s stepmother have gotten only 1 night of sleep per week over this time period. The child wakes every night at midnight and cries inconsolably for a short time before going back to sleep. She does not remember it in the morning. What do you advise: a. Wake her every night at 11:45pm for 10 minutes for 7 days b. No naps at day care c. No liquids two hours prior to bedtime
a. Wake her every night at 11:45pm for 10 minutes for 7 days - actually need to do it for 4 weeks to see improvements - only intervene to stop them from hurting themselves (child has night terrors)
96
Description of night terrors. List two things to do for management.
o education and reassurance (self-limited) -avoid sleep restriction and caffeine (which both increase Slow Wave Sleep) -scheduled awakenings 15-30 min prior to expected episode if occurring nightly - need to do this for 2-4 weeks
97
Signs of toilet readiness? a. able to dress and undress himself. b. desire to please based on positive relationship parents c. can stay dry overnight d. can communicate need for toilet using full sentences
b. desire to please based on positive relationship parents
98
An 8-year-old with primary nocturnal enuresis has tried the alarm for 8 weeks without success. He wants to go to summer camp. The best option is: a) DDAVP b) amitriptyline c) imipramine at bedtime d) imipramine 25 mg tid
a) DDAVP Desmopressin (synthetic ADH) work short term and best for camps and sleepovers. Avoid fluids 1hr before and 8h after - note: imipramine is a TCA and can be used at bedtime (takes one week to reach effect); DDAVP better option
99
What would you suggest for a 7-year-old boy with nocturnal enuresis who sleeps through the night: a) DDAVP b) imipramine c) conditioning alarm d) parent awakening program
c) conditioning alarm 50% cure rate long term, but most effective treatment we have; needs motivation of child and whole family; can also just wait it out and not do anything
100
Mother comes to see you about starting to toilet train her child. What 5 questions can you ask her to assess for readiness.
o Gross Motor ▪ Able to walk to the potty chair (or adapted toilet seat) ▪ Stable while sitting on the potty (or adapted toilet seat) o Control ▪ Able to remain dry for several hours o Language ▪ Receptive language skills allow the child to follow simple (one and two step) commands ▪ Expressive language skills permit the child to communicate the need to use the potty (or adapted toilet seat) with words or reproducible gestures o Social ▪ Desire to please based on positive relationship with caregivers ▪ Desire for independence , and control of bladder and bowel function
101
4 year old with primary enuresis. What is one important piece of advice that you should give to the parents?
This is still within a normal range to not yet be dry; avoid battles over toilet and provide encouragement and praise any successes; no punishment or humiliation
102
All of the following are features of sleepwalking EXCEPT: a) occurs during stage 4 non-REM sleep b) positive family history c) can walk around furniture d) do not walk into dangerous areas e) resolve spontaneously in later childhood
d) do not walk into dangerous areas
103
2 year girl who has episodes of abnormal breathing and movements. Occurs when watching TV or bored. Mum can decrease length of episodes when talking to her. Episodes last 5-6 min. She seems responsive throughout the episodes. What do you recommend to do to mum (1)?
Reassure - infantile masturbation
104
A child who is described as having a learning disability, has big ears. Mom has an LD as well. What to tell mom to expect: 1. Problems with tics 2. Problems with athetosis 3. Problems with hyperactivity 4. Problems with tremor 5. Problems with nystagmus
3. Problems with hyperactivity Fragile X associated with hyperactivity (80% have ADHD)
105
An 8 year old boy at risk for failure in school is sent to your office for evaluation for specific learning disorders. History and physical exam are within normal limits. Which of the following do you do next: a. Trial of stimulant medication b. Psychological assessment c. CBC, TSH and Pb level
b. Psychological assessment Specific LD - most common is reading disorder (dyslexia) - 80% of kids with LD - NO Ix beyond history, physical and psychometric testing needed
106
A 10 year old boy with a history of myelomeningocele and VP shunt placement for hydrocephalus comes to your office with a history of a recent decline in school performance of several months duration. There are no specific neurological, urological or MSK complaints and he does not complain of any pain. A CT scan is done and does not show any change from previous. Which of the following is your next step in management: a. EEG b. Psychological assessment c. Assessment by neurosurgery d. Trial of stimulant medication
a. EEG - can develop shunt-related epilepsy - recent rapid decline over a few months more suggestive of something like absence seizures than an underlying cognitive/LD that has never been a problem before
107
3 yo with isolated language delay. What do you tell mom he is at risk for? a. Reading disability b. ADHD c. Articulation disorder.
a. Reading disability (dyslexia)
108
2.5 year old child. Which is most consistent with an expressive language disorder? a. 100 word vocabulary b. no pronouns c. no 2-word combos d. stuttering
c. no 2-word combos
109
17. Child with dysfluency. List four indications to refer to speech therapy.
Dysfluency = stuttering - 3 or more dysfluencies per 100 syllables - avoidances or escapes (pauses, head nod, blinking) - discomfort or anxiety while speaking - suspicion of associated neurologic or psychotic disorder
110
What is the best predictor of difficulty reading in JK?
- Language disorder o Strongly related to later reading disorder
111
Teacher concerned about 4 yr old child who can't use scissors, can’t copy a square... she wonders about developmental coordination disorder. List 2 diagnostic criteria for developmental coordination disorder.
A) Acquisition/ execution of coordinated motor skills below expected (clumsiness, slowness, inaccuracy of skill) a. Examples: catching, using scissors/cutlery, handwriting, riding a bike, sports B) Significantly/ persistently impairs activities of daily living (self-care and self-maintenance) and school productivity, activities, play C) Onset in early developmental period D) Not better explained by ID, visual impairment or neurological condition
112
A 6-year-old boy has been having involuntary tics for approximately 1 month. He is in grade 1 and doing well. His mother feels that their onset correlates with the death of his grandfather. You suggest: a) wait b) refer to psychiatrist c) treatment with haloperidol d) treatment with methylphenidate e) tell his mother that he will have Tourette’s syndrome
a) wait - treat tics only if interfering with function and are a problem for the CHILD - need at least 1 year of symptoms for tourette
113
You are about to put a child on stimulant medication for his ADHD. The mother asks you about the potential for increasing his potential for future drug addiction. What do you counsel her about her son’s future risk: a. Stimulants have no effect on risk of drug addiction b. Stimulants decrease future risk of drug addiction c. There is an increased risk of drug addiction, but less so with the dextroamphetamines
b. Stimulants decrease future risk of drug addiction
114
Mother brings in her child who has a diagnosis of ADHD, you are treating him with long-acting Ritalin. What is a late onset side effect of stimulants: a. Decreased appetite b. Difficulty sleep c. Tics d. Depression
d. Depression
115
What is true about methylphenidate: a) stimulates appetite b) no effect on growth velocity - does reduce growth velocity but does not seem to have an impact on final adult height c) may exacerbate tics d) can cause dependency e) effective in 60% of children with ADD
ANSWER: c) may exacerbate tics b) no effect on growth velocity - does reduce growth velocity but does not seem to have an impact on final adult height
116
A 6 yo boy in grade 1 is not paying attention, disruptive, in danger of failing. He does not read or write as well as his classmates. Appropriate action: a) fail him b) full psychoeducational assessment c) Ritalin d) classic slow learner
b) full psychoeducational assessment
117
Which is true of ADHD? 1. teacher and parent reporting of symptoms on a checklist frequently agree 2. check for lead poisoning in each kid with ADHD 3. 25% of kids with ADHD have comorbid anxiety disorder 4. kids with ADHD often have thyroid hormone abnormalities
3. 25% of kids with ADHD have comorbid anxiety disorder
118
Which of the following medications used to treat ADHD is not a stimulant? a) Concerta b) Dexadrin Spansules c) Biphentin d) Strattera e) Ritalin SR
d) Strattera (NON STIMULANT= Second line Non stimulant Agent= generic name Atomoxetine - SNRI) - good if comorbid anxiety disorder a) Concerta (Methylphenidate group= Ritalin, Biphentin, Concerta) b) Dexadrin Spansules (Dextroamphetamine Group= Dexedrine, Adderall, Vyvanse) c) Biphentin (see above) e) Ritalin SR (Yes Methylphenidate group)
119
An 8 year old boy with his father is seen for school concerns. There have been concerns raised by his teacher that he is not getting his schoolwork done. He needs reminders to do his work constantly. He is often chatting in class and often out of his seat. His medical history is unremarkable. His hearing is normal. His parents report similar concerns doing homework. What would be your initial course of action? a) Trial of stimulant medication b) Behavioural management referral c) Family counseling d) Psychiatric referral e) Evaluation of academic skills
a) Trial of stimulant medication If kid under 6, trial behavioural strategies first
120
Teen with ADHD, 14 lb weight loss. Currently ADHD is better controlled on his long-acting ADHD med. What is the best thing to do? a. start Straterra b. Consult a psychiatrist c. Change from 7 days a week dosing to 5-days a week.
c. Change from 7 days a week dosing to 5-days a week.
121
Name 3 DSM-V diagnostic criteria for ADHD - inattentive subtype.
- lacks attention to detail/careless mistakes - cannot sustain attention - does not listen when spoken to directly (mind wandering) - does not follow through (starts but does not complete chores, homework) - poor organization/time mgmt - avoids tasks requiring sustained mental effort - loses important things - easily distracted - forgetful about daily activities
122
Name 3 DSM-V diagnostic criteria for ADHD hyperactive/impulsive subtype.
- fidgets/taps hands/squirms - leaves seat inappropriately - runs or climbs inappropriately - unable to play quietly - is “on the go” - talks excessively - blurts out answers, completes peoples’ sentences - cannot wait turn (e.g. in line) - interrupts or intrudes on others
123
How many criteria are needed for a diagnosis of ADHD mixed sub-type.
meet diagnostic criteria for both inattentive AND hyperactive subtype (6/9 for both - i.e. have minimum 12 symptoms)
124
Describe a child having difficulty in school. Teacher complains child not listening in class. Not getting homework done. List 3 things on your differential diagnosis.
- Hearing loss, learning disability, ADHD
125
Kid with known separation anxiety. Management of school phobia? a. Return to school immediately b. Return gradually with parents leaving gradually c. Give SSRI d. Give benzo
a. Return to school immediately
126
A 10 yo boy has headache, abdominal pain and lethargy anytime of the day . He has missed 30 days of school in 4 months. He has: a) migraines b) school phobia c) Brain tumour
b) school phobia
127
3 mos girl BW SGA at 2200g at GA38, now wt 10th, ht 25th, HC 50 th 1. 2 yr for catch up growth in IUGR 2. f/u in 6 mos no nutritional intervention 3. need w/u for organic FTT 4. increase dietary protein 5. if not at 50th %ile by 6 months then needs work up for organic FTT
1. 2 yr for catch up growth in IUGR
128
A 3 year old child comes to your office with concerns of failure to thrive. He is impulsive and destructive in your office and hugs you repeatedly on his first visit. He only says 8 words and does not form 2 word sentences. His mother states that he has a voracious appetite. What is his diagnosis: a. psychosocial deprivation b. attention deficit disorder c. diencephalic syndrome
a. psychosocial deprivation
129
Child with severe trigonocephaly. What is your management? 1. sablage of metopic suture 2. helmet 3. place child face down 4. craniostomy with removal of metopic suture
4. craniostomy with removal of metopic suture - if very mild, no treatment needed
130
A child has sustained a head injury and has been intubated in ICU with a fluctuating GCS of 6-9 for several days. There is no evidence of intracranial bleeding or cerebral edema. Upon discharge, the mother can expect her child to develop: a) fine motor problems b) seizures c) insomnia d) behavior problems e) psychiatric problems
d) behavior problems -cognition is most affected following TBI - also develop behavioural issues, and problems with learning, memory
131
Sign of sexual abuse? a. Midline anal tag b. Scar outside of midline anus c. Atrophic shiny vaginal mucosa d. Big rectum \> 2 cm with lots of stool
b. Scar outside of midline anus (suggestive of abuse per AAP paper on signs of sexual abuse) NOTE: c. Atrophic shiny vaginal mucosa - normal description of vaginal mucosa prior to exposure to estrogen
132
A 9 year old is seen in your office with symptoms of depression and suicidal ideation. Which of the following is a risk factor for this presentation: a. Bullying b. Recent parental divorce c. Impulsive behaviour d. Poverty
a. Bullying (likely most correct given CPS and Nelson’s) recent divorce is also a risk factor, but if divorce leads to resolution of frequent conflict can actually be a relief for kids
133
An 8 year old child is slow to write because he checks each letter 3 times as he writes it. He has no trouble in his interpersonal relationships. What is the diagnosis: d. Normal behaviour e. OCD f. ADHD
e. OCD
134
An 11 year old girl with a maternal history of bipolar disorder has recently become irritable and restless. She is only sleeping 5 hours per night. What is her most likely diagnosis: g. New onset of ADHD h. Bipolar disorder i. Marijuana abuse
h. Bipolar disorder BPD is very heritable
135
The following is true of post traumatic stress disorder a. Intrusive memories b. Vegetative symptoms c. No emotional disturbances prior event
a. Intrusive memories
136
A 2 year old child cries when mother is leaving for work everyday. She is also attached to a “special” teddy bear. What should be done? a) remove child’s teddy bear since this is abnormal attachment to an object b) reassure parents that this is normal separation anxiety appropriate for child’s developmental level
b) reassure parents that this is normal separation anxiety appropriate for child’s developmental level 18-24 months - increased clinginess around 18 months - parents feel they “can’t go anywhere” without a kid hanging off them - separation anxiety often manifests at bedtime - many children use a special blanket or stuffed toy as a transitional object
137
Question on car seat indications. When can the child use regular seat belt? a) When child weighs 41 lbs b) If child is \> 6 yrs old c) when child, while in booster seat, has level of ears over headrest of the seat d) when child has a sitting height at or greater than 63 cm
c) when child, while in booster seat, has level of ears over headrest of the seat
138
You are treating a child, and you have a suspicion of Munchausen by Proxy disorder ( now falls under category of factitious disorder imposed on another in DSM V) . Define MBPD (1 line). Name 3 features that are characteristic of MBPD.
1. Form of maltreatment in which parent simulates or causes disease in their child o Reported symptoms only by one parent o Testing fails to identify medical diagnosis o Appropriate treatment ineffective
139
A child shows features of Obsessive-Compulsive disorder. Define obsession and give 1 example (2 lines). Define compulsion and give 1 example (2 lines).
1. Obsessions: recurrent and persistent thoughts, urges or images that are intrusive and unwanted and cause distress - e.g. bodily wastes and secretions, fear of something calamitous, fear of contamination 2. Compulsions: repetitive behaviours or mental acts performed in response to an obsession according to rigid rules. Acts are aimed at reducing anxiety but are not logically connected to the obsession they are neutralizing - e.g. hand washing, checking of locks, washing and cleaning
140
What criteria is a necessity for the diagnosis of OCD to be made (1 line)?
Presence of obsessions, compulsions or both that are time consuming, distressing and unwanted
141
Which of the following medications causes sexual dysfunction? a) Calcium Channel Blockers b) Antidepressants c) Beta-2 agonists d) Theophylline
b) Antidepressants
142
Which of the following is a late side effect of ADHD stimulant treatment? a) Decreased weight gain b) Sleep difficulties c) Tics d) Depression
d) Depression
143
Child on risperdol for Tourette syndrome has frequent syncopal episodes with exertion. What is the cause? a) hypoglycemia b) Prolonged QT
b) Prolonged QT
144
List 3 serious side effects of risperidone, in addition to weight gain
- long QT - neuroleptic malignant syndrome - agranulocytosis
145
A teen in your practice has been on fluoxetine and risperdal. He presents to your office with hyper-reflexia and tremor and ataxia and 5 or 6 more symptoms. What to do you do? a. stop fluoxetine b. decrease fluoxetine c. increase fluoxetine d. decrease respirdal
a. stop fluoxetine serotonin syndrome: usually rapid onset, mild symptoms incld increased HR, shivering, diaphoresis, dilated pupils, myoclonus, hyperreflexia, hypervigilance, insomnia, agitation
146
Patient has been treated with prozac for 2 years. What is the chance of recurrence of depression once she is taken off this medication? a) 10% b) 20% c) 40% d) 75% e) 90%
c) 40% The risk of recurrence ranges from 34% to 50% within the first year after discontinuation of treatment Response rates to SSRIs in the treatment of depression are 40-70%
147
Describe a kid who has a change in behaviour over the last year. No longer gets As. Not interested in sports. Parents divorces 2 years ago. Picks on sister. Most likely dx? a. Adjustment d/o b. Major depressive d/o c. Substance abuse d. ADHD
b. Major depressive d/o
148
Teen with change in his behaviour. Mgt? a. Psychology assessment b. TSH c. Tox screen
c. Tox screen
149
A girl is referred to you for assessment of possible ADHD. She has been agitated, irritable and is sleeping only 4 hours per night. Her mother has bipolar disorder. What is the most likely diagnosis? a) Drug use b) Bipolar disorder c) ADHD
b) Bipolar disorder - symptoms most in keeping and bipolar disorder is highly heritable
150
A teenager is suspected of having depression by her parents. What five questions would you ask her to make your diagnosis of depression.
Over the last 2 weeks: - depressed mood - loss of interest - increased sleep - feelings of guilt or worthlessness - decreased energy - difficulty concentrating - change in appetite (up or down) - suicidal ideation
151
A mother is concerned that her thirteen year old boy has recently started spending more time in his room, he is more tired and has difficulty awakening in the morning. He doesn’t participate in sports, and spends all of his time on his computer or with his friends. He is doing just below the average in school. When you speak to him, he says he smokes occasionally but denies any other alcohol or drug use. What do you do next: a) Psychological assessment b) Trial of stimulant medication c) Reassure
a) Psychological assessment Sounds typical (increased need for sleep, increased value placed on opinions of friends) but should be screened for depressive symptoms, substance abuse, social anxiety, hypothyroidism, toxic exposures (e.g. lead toxicity)
152
Girl who is shopping lots, irritable, decreased need for sleep and wearing provocative clothing. Family history of suicide. What’s the treatment? a. TCA b. paroxetine c. lithium d. fluoxetine
c. lithium
153
Teen has been depressed since being bullied at school after coming out as a homosexual. He has taken pills from his parents 4 months ago so now all meds in the house are locked up. What to do? a) do not tell his parents because he insists that you don’t tell them b) get more information from the school principal c) he is at low risk for suicide because the pills are locked away d ) he is at increased risk for suicide because he is a homosexual
d ) he is at increased risk for suicide because he is a homosexual
154
A 12 y.o. teen took 10 regular strength Tylenol. What does this act signify a) a plan to die b) a cry for help
b) a cry for help - probably - depends on the intention
155
List 5 risk factors for suicide in teenagers.
- male - aboriginal - LGBTQ - previous attempt - family history of suicide - pre-existing psychiatric illness - negative self-image/hopelessness - lack of social support/living alone
156
Girl with suicidal ideation, admitted. You, the parents, and the patient all agree that she is now ready for discharge. The family lives in a remote community, and there are no mental health resources available over the weekend. List 5 things you would recommend to keep her safe over the weekend before she can be re-evaluated on Monday.
- Recognize personal warning signs - Use coping skills to deal with stress without contacting others - Naming people who can support and distract - Identify close friends/adults who can help resolve a crisis - Knowing mental health professionals/agencies to contact (including local ED and helpline) - ensure safe environment (eliminate access to lethal means ie fire arms, medications) - positive focus to leverage (something to live for)
157
Parents found a boy trying to hang himself and they have brought him in for an assessment. This is a young man troubled by violent thoughts and thoughts of hurting others. Has been able to deal with them for now, but isn’t sure if he can do so in the future. What does he have? a. anxiety b. antisocial personality disorder c. schizophrenia d. depression
c. schizophrenia
158
15 y.o. boy with a history of significant school absenteeism. He has had symptoms of intermittent abdominal pain and recently has developed daily headaches with onset in the later afternoon. He continues to get A’s despite missing 40% of the days in school. His height and weight continue along the same percentiles as previously. What is the most likely diagnosis? a) Anxiety b) Brain tumor
a) Anxiety
159
7 y.o. girl whom you have seen before for her asthma. She has missed 1 month of school because in the morning she complains of feeling “tight”. Later in the day she feels fine and is not missing other extracurricular activities. What is the likely cause? a) generalized anxiety disorder b) depression c) status asthmaticus d) separation anxiety
d) separation anxiety not interfering with other activities; most common form of anxiety in kids; school refusal common
160
7 year old boy described as having separation anxiety. He has just had surgery for appendicitis and since the surgery has refused to go to school. He has always been a good student. What four things would you do in your management?
- work with school personnel - parental mgmt training and family therapy - screen for comorbid mental health conditions (e.g. depression) - screen for medical causes (thyroid disorder, medication side effect) - educate family around importance that he return to school, and not let him stay home as this will make it worse; reward for each completed day at school - SSRIs may be indicated in severe cases
161
7 yo male, separation anxiety, spends time with mother, refuses to go to school. What to do? a) Send back to school immediately b) Send back to school gradually, with mom going to school c) Give SSRI and send back to school
a) Send back to school immediately
162
11 year old with severe symptoms of separation anxiety. Very worried about something happening to his parents (and to him). Best treatment? a. Desensitization b. SSRI c. Parent therapy
b. SSRI (because symptoms severe)
163
15 y.o. girl with frequent brief attacks where she feels short of breath and vaguely uneasy. Which of the following would support your diagnosis. a) Fear of episodes recurring and sudden onset of episodes b) Family history of OCD c) History of emotional trauma
a) Fear of episodes recurring and sudden onset of episodes - panic attacks
164
15 year old girl with rapid onset episodes characterized by intense fear and discomfort lasting few minutes to few hours. Which of the following will help establish the diagnosis: a) episodes occur post specific anxiety provoking situation b) previous emotional trauma c) episodes occur unexpectedly and she would fear more of these episodes d) obsessions and compulsions
c) episodes occur unexpectedly and she would fear more of these episodes
165
A child presents with recurrent episodes of tachypnea, tachycardia, diaphoresis, nausea and vomiting. This occurs twice per week, never at school, for past six months. What is the cause? a) panic attacks b) social phobia c) arrhythmia
a) panic attacks
166
Which of the following treatments have been proven to be effective? a) behavioural therapy for social phobia b) paroxetine in panic disorder
a) behavioural therapy for social phobia - panic disorder treatment is CBT +/- SSRI but generally would use fluoxetine, not paroxetine in kids
167
A teen with panic attacks (described). a) What is the most likely diagnosis? b) What are 2 treatment modalities?
b) CBT - SSRIs
168
A teenage boy admits to having violent thoughts which overwhelm him. He says the thoughts are frequent and that he has not hurt anyone yet, but fears that he will soon. What diagnosis is most likely. a) Behavioural problems b) OCD c) Schizophrenia d) Antisocial personality
b) OCD - less likely schizophrenia because he has insight and finds the thoughts distressing
169
6 y.o. boy with 2 weeks of sudden onset of OCD behaviors. Which infectious agent would you be concerned about? a) Strep pneumonia b) Group A strep c) E.Coli d) H. Influenzae e) Echovirus
b) Group A strep PANDAs
170
10 y.o. female with long history of handwashing 10-12 times per day. Now handwashing 100 times per day. She also has new onset eye blinking and throat clearing. She had a sore throat 2 weeks ago. What should she be treated with? a) Risperidol b) Clonidine c ) Penicillin d) Dexedrine
c ) Penicillin (only treat if existing strep symptoms; antibodies not bacteria is cause) Unproven hypothesis- routine diagnostic lab testing for GAS and ASOT, long term antibiotics, or IVIG/ plasma exchange to treat exacerbations are NOT recommended \*Main issue here is OCD symptoms so if you were going to treat anything medically you should treat her OCD (with an SSRI)
171
A child is referred for evaluation of ADHD. He is have trouble finishing work at school. He is very slow at writing and copies over his letters 3 times. No problems with class disruption, inattentions, hyperactivity or peer relationships. What is the diagnosis? a) ADHD b) OCD c) Anxiety disorder
b) OCD
172
Give two characteristics of “obsessions” in the diagnosis of Obsessive Compulsive Disorder.
- recurrent and persistent thoughts, urges or images - intrusive and unwanted - cause anxiety and distress
173
Boy with ++ worries about his mom, then walks to school and steps over cracks but if he doesn't he has to walk around a car three times. what would be most helpful for him: a) desensitization b) fluoxetine
a) desensitization - part of CBT which is first line for mild-moderate OCD - fluoxetine is a good treatment for more severe OCD
174
Trichotillomania, which is true? a) is associated with OCD in older kids b) is usually self-limiting c) is rare
a) is associated with OCD in older kids
175
A girl with PTSD. List 4 characteristics of PTSD.
- exposure to actual or threatened death, serious injury or sexual violence - re-experiencing of event - avoidance of situations that remind them of event - negative thoughts or feelings following traumatic event (amnesia, self-blame, negative self image, anhedonia) - hyperarousal (irritation, aggression, poor sleep or concentration, easily startled)
176
5 yr old with 21 yr old single mom. Teacher says she is hyperactive, hoarding food and not remorseful for inappropriate behaviour. No eye contact with mom, but runs up and hugs you. Most likely diagnosis? a. ADHD b. Autism c. Attachment disorder
c. Attachment disorder
177
Kid eats like crazy, very skinny, runs up to hug you. What does this kid have? a. diencephalic syndrome. b. emotional deprivation
b. emotional deprivation \*diencephalic syndrome: Severe emaciation/FTT despite normal/increased appetite and preserved ht/length curve o Accompanied by: overactivity, hyperkinesia, euphoria, vomiting, nystagmus - associated with low grade astrocytomas in anterior hypothalamus
178
Child comes to the office because his teacher wants him investigated for disruptive behaviour and is concerned about ADHD. Parents may have some concerns about his attention but none about his behaviour A) What do you think is the diagnosis? B) What are 4 things to request to investigate for this diagnosis?
A) Likely ADHD B) SNAP scales for parents and teachers Report cards Thorough physical exam to rule out comorbid medical condition Vision and hearing screening Developmental assessment Consider psychoeducational testing Consider genetic testing Consider screening blood work (thyroid, lead level)
179
A guidance counselor calls you about a 12 y.o from Inuit population. He things that the boy may have ADHD. Give four other things on your differential diagnosis.
- learning disability - hearing or visual impairment - FASD - substance use - anxiety or mood disorder - fragile X - medical disorder (hyperthyroid, lead poisoning)
180
Teen with ADHD, 14 lb weight loss. Currently ADHD is better controlled on his long-acting ADHD med. What is the best thing to do? a. start Straterra (Atomoxetine) b. Consult a psychiatrist c. Change from 7 days a week dosing to 5-days a week
c. Change from 7 days a week dosing to 5-days a week
181
A 13y.o. boy with ADHD is taking 36mg of Concerta. His symptoms and school performance have improved and his mother is happy with his improvements. For the past 2 weeks, however, he has been sad, often crying unpredictably. He also is having difficulty falling asleep at night. What is the next best step in his management? A) Decrease the dose of Concerta to 28mg B) Change from Concerta to Adderall C) Add fluoxetine D) Add melatonin
B) Change from Concerta to Adderall
182
7 yo male with normal intelligence is struggling at school. He cannot read aloud and doesn’t understand reading material but can learn when read to. What is the cause? a) ADHD b) Expressive aphasia c) Global delay d) Dyslexia
d) Dyslexia - learning disorder (underperforming compared to his intelligence)
183
A 4 year old boy has trouble with expressive language. Currently speaks only 50 words and is using 2 word phrases. His receptive language is good. Development otherwise normal (build 12 piece puzzle and house with Lego). What is he most likely at risk for? a) developmental disability b) difficulty with reading c) Autism spectrum disorder d) ADHD
b) difficulty with reading early lang disorder strongly related to reading disorder (50%), early lang dx (esp auditory comprehension) RF for later emotional dysfunction (higher rate of anxiety)
184
10 y.o. boy steals, kills a pet and lights fires. What is the diagnosis? a) ODD b) ADHD c) Conduct disorder d) Antisocial personality trait
c) Conduct disorder
185
A 13 y.o. boy presents to your office with a history of being argumentative with his teachers at school, skipping class and refusing to obey his parents’ rules at home. a) What is the most likely diagnosis b) Name 2 treatment modalities that may be beneficial in this situation
a) Oppositional defiance disorder b) parent training (e.g. triple P parenting program) to strengthen child-parent relationship, and youth training to learn how to deal with anger-provoking situations - anger mgmt programs for youth (Coping Power) - medications (stimulants or atypical antipsychotics)
186
4 specific behaviours in an adolescent with conduct disorder
- Aggression to people and animals/violation of the rights of others - Destruction of property - Deceitfulness or theft - cruelty to animals - truancy before age 13 - run away from home 2+ times
187
17 year old teen with persistent issues with negative evaluation, fear of social situations. What is the most likely? a. avoidant personality disorder b. anxiety disorder c. depression
a. avoidant personality disorder (anxiously detached, hypersensitive to negative evaluation)
188
Tourette’s Syndrome. a) List 3 diagnostic criteria b) List 3 associated conditions
a) 2 motor + 1 vocal tic; min. 1 year; onset \< 18 y.o. b) ADHD, OCD, LD
189
A kid presents with facial tics. What would support a diagnosis of Tourette’s? a. tics are present for 6 months b. family history of tics c. attention-deficit, hyperactivity disorder
b. family history of tics ( usually + FHX) \*2/3 of patients with Tourette's do have ADHD
190
Child presenting with writing difficulties and seems moody. What does she have? a. Lupus b. Sydenham’s chorea c. Tourettes d. Huntington’s disease
b. Sydenham’s chorea SLE also possible, but epidemiologically less likely
191
A 14 y.o. boy recently has had 2 weeks of personality changes, saying weird things, staying in his room and not going to school. (No comments on any physical symptoms.) List 4 causes on your differential diagnosis.
- Brief Psychotic Episode - Substance use - Mood Disorder (depression) - Medical Condition (brain tumour)
192
A 15 y.o. boy is brought in by his parents because he is locking himself in his room and is hearing voices. He broke up with his girlfriend 2 weeks ago. a) What is the differential diagnosis? b) List 4 non-psychiatric diagnoses for psychosis/delirium.
a) Adjustment Disorder, Substance Induced, Brief Psychotic Episode, Schizoaffective disorder b) toxins/drugs, infection (encephalitis, meningitis), metabolic (B12, folate deficiency, hyperthyroidism, late onset CAH), liver failure (hepatic encephalopathy), brain tumour
193
11 year old boy who has had recent personality changes, decline in school performance and visual changes. Which is the first diagnosis to rule out: a) Brain tumour b) T1DM c) ADHD
a) Brain tumour
194
Teen boy locked in room talking to himself, mother thinks he thinks he hears voices. What is the most likely diagnosis? a. drug abuse b. brain tumor c. schizophrenia d. depression
c. schizophrenia - could also be drug abuse
195
Child has frightening awakenings, screams, cries. No recollection in the morning. What is the most likely diagnosis? a. nightmares b. night terrors
b. night terrors
196
5 things you would tell a boy to improve his sleep hygiene
o Quiet and comfortable sleep environment o Consistent bed and waking time o Avoid stimulation (Tv, computers, video games) o Read or other active stimulation to mentally fatigue o Increase physical activity in daytime (not within two hours of bedtime) o Limit bed use to sleep (not for tv, eating, homework)
197
Divorcing parents. What’s best for the kid? a) best if joint custody could be given asap b) best if child gets to see both parents even if the parents are fighting all the time c) best if parents can settle their differences and not fight in front of kids
c) best if parents can settle their differences and not fight in front of kids
198
Marital troubles at home, child is acting out at school and daycare. Mom has come in for advice. a. give the mom parenting classes b. request a meeting with both parents to assess the home situation c. give him Ritalin
b. request a meeting with both parents to assess the home situation
199
Parents, children and divorce- what is true? a) males respond better to divorce in the immediate post divorce period than females b) Children do better in a 1 parent custody setting without seeing the other parent c) The best predictor of the child’s response is post separation parental conflict and depression rather than custody issues
c) The best predictor of the child’s response is post separation parental conflict and depression rather than custody issues
200
3 reasons you could breach confidentiality.
- Risk to Self (Form 1) - Risk to Others (Report to police) - Risk to other children (Child Protection Services) - Reportable Infections (Public Health)
RC Study Cards
flashcards
Decks in class (23)
# Cards
-
Acute Care270
-
Adolescent/Gyne98
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Allergy/Immunology70
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Cardiology136
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CYPT and Ethics64
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Dermatology70
-
Endocrinology161
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ENT/Ophtho/Gen Surg149
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Gen Paeds0
-
Genetics179
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GI/Nutrition146
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Heme/Onc106
-
Infectious Disease271
-
Metabolics27
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MSK/Ortho/Rheumatology138
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Nephrology/Urology154
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Neurology110
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NICU233
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Pharm and Critical Appraisal57
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Psych/Development200
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Respirology152
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ADHD13
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Syndromes102
