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2018 Peds Royal College Psych > 2018 Peds Royal College Psych > Flashcards

2018 Peds Royal College Psych Flashcards

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1
Q

DSM-V ADHD

A
  • Onset prior to age 12
  • Must be present in 2 or more settings
  • Symptoms interfere with occupational, social, academic functioning
  • Does not occur exclusively during schizophrenia or psychotic disorder and not explained by a different mental health disorder

Hyperactive/Impulsive:

  1. Excessive fidgeting
  2. Difficulty remaining seated
  3. Feelings of restlessness or inappropriate running around
  4. Difficulty playing quietly
  5. Difficult to keep up with “always on the go”
  6. Excessive talking
  7. Difficulty waiting turns
  8. Blurting out answers quickly
  9. Interruption or intrusion of others

Inattention:

  1. Failure to provide close attention to detail, making careless mistakes
  2. Difficulty maintaining attention
  3. Seems to not listen, even when directly addressed
  4. Fails to follow through (eg. homework, chores)
  5. Difficulty organizing tasks, activities and belongings
  6. Avoids tasks that require consistent mental effort
  7. Loses objects
  8. Easily distracted by irrelevant stimuli
  9. Forgetfulness in routine activities

Single subtype: 6 or more features
Mixed subtype: 6 or more features in each category

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2
Q

Late side effect of stimulants

A

Depression

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3
Q

Differential diagnosis ADHD

  • Psych
  • Medical/genetic
A
  1. Learning disability
  2. OCD
  3. OSA
  4. Hearing impairment
  5. Hyperthyroid
  6. Autism
  7. Substance abuse
  8. Fragile X
  9. Intellectual disability
  10. Anemia
  11. Lead poisoning
  12. Medication side effect
  13. Metabolic disorder
  14. CNS infection
  15. Head trauma
  16. Neglect/abuse
  17. Adjustment disorder
  18. Food insecurity
  19. FASD
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4
Q

Management of weight loss on stimulants

A
  1. Decrease use to 5x/week
  2. Change to strattera
  3. Refer to psychiatry
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5
Q 
Best medication for ADHD + history substance abuse
A. Guanfacine
B. Vyvanse
C. Adderall
D. Dextrin
A

B. Vyvanse

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6
Q

Psych comorbidities with ADHD

A
  1. OCD
  2. LD
  3. ODD
  4. CD
  5. ASD
  6. Tic disorder
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7
Q

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

A

B. Stimulants decrease future risk of drug addiction

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8
Q

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:
A. New onset of ADHD
B. Bipolar disorder
C. Marijuana abuse

A

B. Bipolar disorder

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9
Q

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
A
  1. 25% of kids with ADHD have comorbid anxiety disorder
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10
Q

DSM-V for OCD

A

A. Presence of obsessions, compulsions or both
Definition of obsessions:
1. Recurrent and persistent thoughts, urges or images that are intrusive and cause distress
2. Individual attempts to ignore or suppress or neutralize them with some other thought or action
Definition of compulsions:
1. Repetitive behaviours that they must perform in response to an obsession or according to rigid rules
2. The behaviours are aimed at reducing some anxiety or distress or preventing some dreaded event. The behaviours are not connected in a realistic way to what they are trying to prevent, or are clearly excessive.

B. Obsessions or compulsions are time-consuming (>1 hr/day) or cause clinically significant distress or impairment in function

C. Not attributed to a substance or medical condition

D. Not explained by another mental disorder

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11
Q 
10 yo 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. Risperdal
B. Clonidine
C. Penicillin
D. Dexedrine
A

A. Risperdal

Really, the #1 choice of medication for OCD plus tics is an SSRI - then add an atypical antipsychotic

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12
Q

Trichotillomania
A – is associated with OCD in older kids
B – is usually self-limiting
C – is rare

A

A - associated with OCD in older kids

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13
Q 
A teenage boy is having difficulties functioning because he constantly has to watch his hands and has obsessive thoughts.  Which of the following medications may help him?  (MCQ 2008)
1.  Amitryptiline
2.  Clonazepam
3  Clozapine
4.  Fluoxetine
A
  1. Fluoxetine
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14
Q

Define obsession, give an example

A

Recurrent and persistent thoughts, images or urges that are experienced as intrusive or unwanted, that the person tries to suppress or ignore
Example: contamination, aggression or violence, taboo sexual or religious thoughts

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15
Q

Define compulsion, give an example

A

A repetitive behaviour that must be performed in response to an obsession or according to strict rules, aimed at reducing some anxiety or distress that is not realistically connected to the behaviour.
Example: hand washing, checking, counting, ordering, praying

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16
Q

DSM-V for Autism

A

Social interaction/communication

  1. Deficits in social-emotional reciprocity
  2. Deficits in non-verbal communicative behaviour
  3. Deficits in developing, maintaining and understanding relationships

Restricted/repetitive behaviours/interests. Need 2 of:

  1. Stereotyped or repetitive motor movements
  2. Insistence on sameness, inflexibility
  3. Highly restricted, fixated interests
  4. Hyper or hypo-reactivity to sensory input or unusual interest in sensory aspects of environment
  • Symptoms must be present in early developmental period
  • Symptoms cause clinically significant impairment in functioning
  • Not better explained by intellectual disability or GDD
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17
Q

Tests to order for autism

A
  1. Autism screening test
  2. Complete history and physical exam
  3. Audiology testing
  4. Labs: serum lead, fragile X, CGH miroarray
  5. Consider MRI head, EEG and metabolic testing if any indications based on history and physical
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18
Q

Services to consult for help diagnosing autism

A
  1. SLP
  2. Psychology
  3. Occupational or physiotherapy
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19
Q

Genetic disorders associated with autism

A
  1. Fragile X
  2. Rett
  3. NF-1
  4. Tuberous sclerosis
  5. Angelman
  6. Trisomy 21
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20
Q

Neurologic disorders associated with autism

A
  1. Tuberous sclerosis
  2. Rett syndrome
  3. Seizures
  4. NF
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21
Q

Screening tools and ages for autism

A 
ITC = 9-24 months
M-CHAT = 16-30 months
CAST = 4-11 years
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22
Q

What is true about methylphenidate:

a) stimulates appetite 
b) no effect on growth velocity
c) may exacerbate tics 
d) can cause dependency
e) effective in 60% of children with ADD
A

d) can cause dependency

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23
Q

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

A

B. Developmental disorder

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24
Q

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

A

C. Does not point to things to show interest

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25
Q

Proto-imperative vs proto-declarative pointing

A 
Imperative = pointing to a desired object
Declarative = using pointing to draw someone’s attention
26
Q

Which is more consistent with autism?

Lack of protoimperative or protodeclarative pointing

A

Protodeclarative pointing

- using pointing to draw someone’s attention

27
Q

Features of Rett syndrome

A
  1. Acquired microcephaly
  2. Repetitive hand-wringing movements and a loss of purposeful and spontaneous use of the hands (hallmark of Rett syndrome which may not appear until 2-3 yr of age)
  3. Developmental regression (after around 12m)
  4. Autistic behavior (typical finding in all patients)
28
Q

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

A) Wait

notes…
B) for CBT if persistent or apparent anxiety/compulsive sx emerge also
C) not first line and don’t jump to meds with tics
E) may not evolve to chronic

29
Q

DSM-V Tourette

A
  1. Two or more motor tics and at least one vocal tic, although they might not always happen at the same time.
  2. Tics present for at least a year. The tics can occur many times a day (usually in bouts) nearly every day, or off and on.
  3. Tics begin before he or she is 18 years of age.
  4. Symptoms not due to taking medicine or other drugs or due to having another medical condition
30
Q

Comorbidities with tics

A
  1. ADHD
  2. OCD
  3. LD
  4. ODD
  5. CD
31
Q

Management of tics

A
  1. Comprehensive behavioural therapy

2. Alpha-agonists (clonidine or guanfacine)

32
Q

The following is true of post traumatic stress disorder

a. Intrusive memories
b. Vegetative symptoms
c. No emotional disturbances prior event

A

a. intrusive memories

33
Q

DSM-V for PTSD

A
  1. Exposure to an actual or threatened death, serious injury or serious violence. May be direct, witnessed or learning that the events happened to a family member or close friend.
  2. Presence of intrusive symptoms
  3. Persistent avoidance of stimuli associated with the traumatic event
  4. Negative alterations in cognition and mood associated with the traumatic event
  5. Marked alterations in arousal and reactivity associated with the event
  6. Duration > 1 month
  7. Causes clinical impairment
  8. Not attributable to a substance
34
Q

DSM-V for learning disability

A
  1. Difficulty learning and using academic skills in specific areas for at least 6 months despite interventions
  2. Level of specific academic skill is substantially below what would be expected for age. This significantly interferes with
    academic performance or other areas of daily living.
  3. Onset during school-age years.
  4. Not better accounted for by other factors such as intellectual disability, inadequate academic instruction in the language of proficiency, psychosocial adversity, or other mental or neurological disorders.

Specifier: impairment in reading, written expression, spelling, mathematics, decoding words

35
Q

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

A

c. Reading disorder

Pronunciation and reading difficulties go together

36
Q

DSM-V for Childhood onset dysfluency disorder

A

A. Dysfluency in the normal fluency and time patterning of speech that is inappropriate for developmental stage. Persists over time and includes one or more of:
1. Sound and syllable repetitions.
2. Sound prolongations of consonants as well as vowels.
3. Broken words (e.g., pauses within a word).
4. Audible or silent blocking (filled or unfilled pauses in speech).
5. Circumlocutions (word substitutions to avoid problematic words).
6. Words produced with an excess of physical tension.
7. Monosyllabic whole-word repetitions (e.g., “I-I-I-I see him”)
B. Disturbance causes anxiety or limitations in effective communication or functioning
C. Onset in early developmental period
D. Not attributed to a speech-motor or sensory deficit, neurologic insult or other medical condition and not explained by another mental disorder

37
Q

Features of normal childhood developmental dysfluency

A
  1. Occasional (once per every 10 sentences)
  2. Brief (< 0.5 seconds)
  3. Repetitions of sounds, syllables or words at the start of the word with no prolongations
  4. Worse when tired, excited, complex language, questions, anxious
  5. No facial tension
38
Q

You are seeing a 3.5 year old who repeats words (mommy, mommy, mommy) and beginning of words (m,m,m,mommy), with periods of pausing and not speaking, facial grimacing and blinking.
What should you do?
a) Reassure normal development and reassess in 6 months
b) Refer for audiology testing
c) Refer to speech pathologist for treatment
d) Start clonidine

A

c) Refer to speech pathologist for treatment

39
Q

Indications to refer to SLP for dysfluency

A
  1. 3 or more dysfluencies per 100 syllables
  2. Avoidances or escapes (pauses, head nod, blinking)
  3. Discomfort or anxiety while speaking
  4. Facial tension or grimacing
  5. Preschool or older children
40
Q

Management of oppositional defiant disorder

A
  1. Parental training

2. Treat comorbidities

41
Q

Poor prognostic factors for mood disorders

A
  1. Long duration or severe episodes
  2. Psychotic features
  3. Pre-existing dysthymic disorder/chronicity
  4. ETOH/substance use
  5. Anxiety disorder
  6. > 1 previous episode
  7. Poor premorbid functioning
42
Q

Indications for referral with mood disorder

A
  1. Chronic, recurrent depression
  2. Lack of response to initial course of treatment
  3. Comorbid substance abuse
  4. Recent suicide attempt
  5. Current SI with plan
  6. Psychosis
  7. Bipolar disorder
  8. Family history of bipolar disorder
  9. High level of family discord
  10. Lack of family support in monitoring/follow-up
43
Q 
A 16 year old boy has been treated (by his psychiatrist) with fluoxetine and risperidone for psychotic depression. He was taking risperidone initially for 6 weeks and fluoxetine was added 4 weeks ago. He presents to the ED with 8 hours of ataxia, drowsiness, diarrhea, confusion, agitation. His temperature is 37.6°C. The laboratory tests you order are unremarkable. What is your management approach?
A.Increase the fluoxetine
B.Discontinue the fluoxetine
C.Decrease the fluoxetine
D.Increase the risperidone
E.Decrease the risperidone
A

B.Discontinue the fluoxetine

serotonin syndrome

44
Q

Serotonin syndrome features

A
  1. Autonomic instability (tachycardia, fluctuations in BP, shivering, fever, nausea, vomiting, diarrhea, diaphoresis),
  2. Neurologic symptoms (ataxia, hyperreflexia, tremor, myoclonus),
  3. Mental status changes (hallucinations, confusion, altered level of consciousness, restlessness/agitation, personality changes)
45
Q

Risk factors for suicide

A
  1. Male
  2. Access to firearms
  3. Past suicide attempts
  4. Exposure or FHx
  5. Being bullied
  6. Sexual minority
  7. Bipolar disorder
  8. Intent/plan/means
46
Q

DSM-V for panic attack

A

Abrupt surge of intense fear or intense discomfort that peaks within minutes, includes 4 or more of:

  1. Palpitations
  2. Sweating
  3. Trembling or shaking
  4. Sensations of shortness of breath or smothering
  5. Feelings of choking
  6. Chest pain or discomfort
  7. Nausea or abdominal distress
  8. Feeling dizzy, unsteady, light-headed, or faint
  9. Chills or heat sensations
  10. Paresthesias
  11. Derealization or depersonalization
  12. Fear of losing control or “going crazy”
  13. Fear of dying
47
Q

DSM-V for panic disorder

A

A. both 1 and 2

  1. Recurrent panic attacks
  2. At least 1 panic attack has been followed by 1 month of:
    a. persistent concern about having more panic attacks
    b. worry about the implications or consequences of an attack
    c. significant change in behaviour related to the attacks
  3. +/- agoraphobia
  4. Not due to a substance or medical condition
  5. Not accounted for by another mental disorder
48
Q

DSM-V for social phobia

A

A. Marked fear or anxiety about 1 or more social situations where they are exposed to possible scrutiny by others.
B. Fears that he or she will act in a way or show anxiety symptoms that will be negatively evaluated
C. The social situations almost always provoke fear or anxiety.
D. The social situations are avoided or endured with intense fear or anxiety.
E. The fear or anxiety is out of proportion to the actual threat posed by the social situation
F. The fear, anxiety, or avoidance is persistent, lasts 6 months or more
G. The fear, anxiety, or avoidance causes clinically significant distress or impairment in functioning.
H. Not attributable to a substance or another medical condition
I. Not better explained by the symptoms of another mental disorder
J. If another medical condition is present, the anxiety or avoidance is clearly unrelated or is excessive

Specify if: performance only

49
Q

Which of the following treatments have been proven to be effective:

(a) behavioural therapy in social phobia 
(b) paroxetine in panic disorder
A

(a) behavioural therapy in social phobia

50
Q

DSM-V oppositional defiant disorder

A 
Pattern of pervasivenegativistic/hostile and defiant behaviourfor >6 months and >4 of the following features:
1. Loses temper
2. defies adult rules
3. angry and resentful
4. deliberately annoys/blames others
5. spiteful or vindictive
6. easily annoyed
Causes impairment, does not meet criteria for conduct disorder
51
Q

DSM-V conduct disorder

A

Pattern of behaviourthat violates rights of others and social norms.
>3 in past 12 mos:
1. Aggression to people and animals: bullies, physical fights, uses weapon, physically cruel to people and/or animals, stolen confronting victim, forced sex
2. Destruction of property: firesettingwith intent, destruction of property
3. Deceitfulness or theft: B&E, cons others, stolen nontrivial items without confronting
4. Violation of rules: stays out O/N (before age 13), run away at least twice, truant from school before 13

52
Q

Differential diagnosis psychotic disorder

A
  1. Substance Use Disorder
  2. Major Depressive Episode with psychotic features
  3. Manic Episode with psychosis
  4. OCD
  5. Psychotic Disorder due to a general medical condition (eg. anti-NMDA, seizure disorder, CNS lupus, post-viral encephalitis, temporal lobe lesion)
53
Q

Side effects of risperidone

A
  1. Acute dystonic reaction
  2. Tremor
  3. Sedation
  4. Akithesia
  5. Weight gain
  6. Lethargy
  7. Hyperprolactinemia
  8. Hyperlipidemia
  9. Hyperglycemia/T2DM
  10. Hypertension
54
Q

Medical child abuse definition

A

Child receiving unnecessary and harmful or potentially harmful medical care due to a caregiver’s overt actions including exaggeration of symptoms, lying about the history or simulating physical findings (fabrication), or intentionally inducing illness in their child.

55
Q

Features of child with medical child abuse

A
  1. Symptoms repeatedly noted by only 1 parent
  2. Appropriate testing fails to confirm diagnosis
  3. Appropriate treatment is ineffective
  4. Symptoms, course or response to treatment is incompatible with any recognized disease
56
Q

Features of perpetrator of medical child abuse

A
  1. Female
  2. Factitious or somatiform disorders
  3. Unfortunate childhood
  4. Self-harm, EtOH or drug abuse
  5. Experience working in a medical field
57
Q

Physical findings in anorexia nervosa

A
  1. Bradycardia
  2. Orthostatic hypotension
  3. Lanugo
  4. Hypothermia
  5. Dull, thinning hair
  6. Cachexia
  7. Acrocyanosis
  8. Growth retardation
  9. Pubertal delay or arrest
58
Q

Psych comorbidities with ODD

A
  1. ADHD
  2. Learning disorder
  3. Substance use disorder
  4. Anxiety
  5. Bipolar disorder
59
Q

Questions to ask about depression

A
  1. Have you been experiencing low mood?
  2. Have you experienced decreased interest in activities or areas of interest you used to enjoy?
  3. Has your sleep, appetite, concentration or energy level changed?
  4. Have you had thoughts of suicide?
  5. Have you been feeling guilty?
  6. Have you had difficultly concentrating?
60
Q

Diagnosis of fetal alcohol syndrome

A
  1. History of maternal antenatal alcohol consumption
  2. Poor growth
  3. Characteristic facial features
  4. Neurologic abnormalities
61
Q

Cognitive/behavioural profile for fetal alcohol syndrome

A
  1. Lack of organization
  2. Poor abstract thinking
  3. Inability to foresee consequences
  4. Impulsive
  5. Inappropriate behaviour
  6. Inability to learn from past experiences
  7. Communication problems
  8. Difficulty with adaptive living skills

2018 Peds Royal College Psych (1 decks)

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