Behavioral Medicine And Substance Use

Question 1

An adolescent presents for counseling because of drug dependence.

What are some of the most common risk factors associated with the development of substance use disorder?

Answer 1

Household drug use (especially by parents!), peer group drug use, untreated attention deficit hyperactivity disorder, depression, anxiety disorder, impulse control problems, mood disorders
Explanation
The consequences of substance use can be devastating, frequently leading to accidents, injuries, and death. Associated high-risk sexual behaviors can result in unwanted pregnancy and sexually transmitted infections (including HIV). Continued use of substances can result in fetal anomalies (e.g., fetal alcohol syndrome). Substance use is linked to delinquency and crime. Long-term use has been associated with neuropsychiatric impairment.

Question 2

A healthy teen presents to the emergency department following a syncopal episode after huffing room deodorizer.

What will you look for in your evaluation of this patient?

Answer 2

Answer
Hypotension, cutaneous flushing followed by vasoconstriction, tachycardia ECG changes (inverted T waves, ST depression)
Explanation
Huffing refers to the inhalation of fumes or vapors from a closed container, such as a paper bag, balloon, or soda can. Inhalants are used for their psychoactive properties.

Use of inhalants can be associated with:
Hypotension
Cutaneous flushing followed by vasoconstriction
Dizziness and syncope
Tachycardia ECG changes: inverted T waves, ST depression

Question 3

An adolescent boy presents with:

Dizziness
Dilated pupils
Delusions that he is someone else
He says he “sees smells” and “hears colors.”

What illicit drug did he likely take?

Answer 3

Answer
LSD (lysergic acid diethylamide)
Explanation
LSD is a potent hallucinogen. Classically somatic symptoms (e.g., dizziness, dilated pupils, flushing) occur 1st, followed by perceptual changes (e.g., “seeing smells” or “hearing colors”). Finally, psychic effects (e.g., delusional ideation, body distortion, psychosis) occur.

Question 4

What mental health disorder is characterized by excessive, unrealistic fears that interfere with daily activities?

Answer 4

Answer
Generalized anxiety disorder
Explanation
Generalized anxiety disorder manifests as excessive, prolonged, and unrealistic fear that interferes with daily life. It is caused by a combination of biological, developmental, and environmental factors. Being anxious can be normal in acute settings, but anxiety becomes a disorder when it continues even when the situation is over and it is interfering with daily life. There are several different types of anxiety disorders in children. They break down into 2 categories: generalized anxiety disorder and other anxiety disorders that are specific to a place/item. Generalized anxiety disorder is when a child has excessive anxiety and worry occurring most days for at least 6 months and worries about several events at home/school. This worrying causes significant distress and impairment. Other anxiety disorders include social anxiety disorder and panic attacks

Question 5

A 12-year-old boy presents with repetitive, persistent (> 9 months) behaviors that violate the rights or property of others. He has been stealing, lying, harming animals, setting fires, and fighting. He lacks close friends and is unpopular. He does not have any guilt or remorse about his behaviors. The behaviors occur in the home, school, and community.

What is the most likely diagnosis?

Answer 5

Conduct disorder
Explanation
Conduct disorder is a complex, multifactorial disorder. Generally, think of it in children who have repetitive, persistent (> 6 months) behaviors that violate the rights of others or destroy property. In addition, drug use and sexual abuse are associated with this disorder. Children with conduct disorder do not show remorse

Question 6

Do nightmares occur during REM or non-REM sleep?

Answer 6

REM sleep
Explanation
Nightmares tend to occur during the last 1/3 of the night, and do not typically cause a child to get out of bed. Parental reassurance is the best response.

Question 7

What mental health disorder is characterized by periods of depression alternating with mania?

Answer 7

Answer
Bipolar disorder
Explanation
Bipolar disorder is characterized by alternating periods of depression and mania. Depressive symptoms include fatigue, decreased energy, depressed mood, and anhedonia. Manic symptoms include intense energy, sleeplessness, pressured speech, grandiosity, and risk-taking behaviors. Risk factors include a family history of bipolar disorder, rapid onset of depressive symptoms, and psychotic symptoms. For bipolar patients with mania, treat with an antipsychotic drug (e.g., risperidone, quetiapine) or lithium. Address symptoms of depression with necessary therapies (e.g., individual, family, cognitive behavioral.) Selective serotonin reuptake inhibitors are rarely used in bipolar disorder, as it can shift the mood toward mania. Bipolar disorder is associated with—but does not require—substance use.

Question 8

A 16-year-old girl presents for a behavior consult:

She missed school 3 times last month.
Her parents were unaware of her absences from school.
Her family life is stable, without major disruptions.
What is the likely cause of this girl’s school absenteeism?

Answer 8

Truancy
Explanation
Truancy is a child’s absence from school without their parents’ knowledge or consent. Truancy should not be confused with school refusal. School refusal is defined as a student missing school 2–3 days per week for at least 2 weeks. It usually occurs in conjunction with somatic complaints, is often associated with anxiety and social phobia, and parents are aware of the absenteeism. Parents are an integral part of the team (e.g., parent, teacher, nurse, social worker) mobilized to facilitate school attendance while reducing the child’s anxiety

Question 9

A mother brings in her 8-year-old child with a history of 2 prior admissions for bacteremia: one with E. coli and the other with a mixture of organisms, including E. coli and Serratia. The mother is a nurse in another hospital. The child now presents with fever, hypotension, and shock. Previous workup for immune dysfunction was negative. The mother seems calm that the child is ill again; she is excited for the child to be admitted to the hospital.

What diagnosis should be entertained at this point?

Answer 9

Factitious disorder imposed on another (formerly Munchausen syndrome by proxy)
Explanation
Factitious disorder imposed on another is a bizarre disorder, considered to be a form of child abuse, in which the caregiver-child relationship is disturbed. The mother is almost always involved and commonly works in the health care profession. She is deliberately dishonest about the history of illness in her child and/or harms the child to “create” an illness. Be suspicious on the exam if a child presents with recurrent, serious illness that cannot be satisfactorily explained; e.g., recurrent E. coli bacteremia in an 8-year-old is very unusual, especially with a mixture of gram-negatives (think about mom injecting feces in the child or something similar

Question 10

2-year-old girl started screaming after being told “no” to a second cookie. She suddenly:

gave a few shrill cries followed by brief apnea,
lost consciousness, and
experienced facial cyanosis until breathing resumed.
What caused this child’s apnea?

Answer 10

Breath-holding spell (cyanotic type)
Explanation
Breath-holding spells (cyanotic type) are often associated with temper tantrums. Though frightening, they are benign. Temper tantrums are common in children 2–4 years of age; 20% of 2-year-olds have daily tantrums. Encourage parents to avoid angry responses to tantrums so as not to reinforce the negative behavior. Offering children choices gives them a sense of control and often prevents a tantrum. Once a tantrum has begun, it is best to ignore the behavior. There are 2 types of breath-holding temper tantrums: cyanotic form, in which the face becomes cyanotic until breathing returns; and pale form, in which the face turns pale due to vasovagal syncope. In both types, the entire episode lasts ~ 10–60 seconds. Breath-holding spells usually resolve by 5 years of age.

Question 11

What does thumb sucking that persists into adolescence possibly indicate?

Answer 11

Psychological problems
Explanation
Thumb sucking peaks between 18 and 21 months of age; most children stop by 5 years of age. It occurs in 10–35% of children. Thumb sucking that persists into adolescence may indicate underlying psychological issues, and is more commonly seen in girls.

Question 12

An adolescent with a known history of substance use is arrested on a drunk driving charge and placed in jail. He has been held in jail for ~ 6 hours, and he is now showing noticeable yawning.

What is one of the illicit drug categories that he likely uses?

Answer 12

Opiates (heroin)
Explanation
Heroin withdrawal occurs about 8 hours after the last exposure. One of the first signs is yawning. Then lacrimation, mydriasis, insomnia, “goose flesh,” diarrhea, and systolic hypertension occur. Diazepam is helpful for the withdrawal symptoms; the patient should be managed in a professional setting.

Question 13

A 3-year-old girl is brought in by her mother after she had a temper tantrum, held her breath until she turned blue, and passed out. The mother is worried that the child had a seizure because she had some tonic-clonic movements as well.

What should be the next step in management of this child?

Answer 13

Answer
Reassurance
Explanation
Breath-holding spells are benign. There are no long-term effects and no brain injury. There are 2 forms of breath-holding temper tantrums:

The cyanotic form, in which the face turns blue until breathing returns
The pale form, in which the face turns pale due to vasovagal syncope
Cyanotic episodes are preceded by several shrill cries; pallid spells are preceded by an injury, often with no cries or only 1 cry.

Question 14

You are asked to develop a substance use program for high school students.

What is the most frequently used substance in this target age group?

Answer 14

Alcohol
Explanation
Most teenagers have tried alcohol by the time they are seniors in high school. The mean age for 1st use of alcohol is 12.6 years of age. Most underage drinking is done in the form of binge drinking. Binge drinking refers to the consumption of > 4 drinks within a 2-hour period. Girls and boys drink alcohol at nearly the same rates.

Impaired judgment, abnormal behaviors, and altered level of consciousness can be seen with elevated blood alcohol levels. The diagnosis of acute alcohol intoxication can be made with serum or breath alcohol levels.

Question 15

An adolescent presents to the emergency department after binging on methamphetamines. Body temperature and systemic blood pressure are elevated. He has an irregular heart rate.

How would you manage this patient?

Answer 15

Cooling blankets; lorazepam or diazepam
Explanation
Methamphetamine (a.k.a. Ice, Meth) can be administered by mouth, through inhalation (smoking), through mucous membranes, or by injection. Methamphetamine is a psychostimulant that promotes the release and inhibits the reuptake of monoamine neurotransmitters. Effects can be dose related. Tachycardia and dysrhythmias can be seen at lower doses, while higher doses are associated with hyperpyrexia, ventricular irritability, elevated blood pressure, and seizures. Dry mouth leading to tooth decay (“meth mouth”) can occur. Behavioral findings include agitation and delusional behaviors. These can be treated with haloperidol or droperidol. Psychological cravings, mood swings, paranoia, and disorganized thinking may develop as soon as 2 days after cessation; however, they may be delayed up to 2 weeks after last use. Craving considerably drops after 2 weeks but persists at a lower level for up to ≥ 5 weeks.

Question 16

W hat is the recommended age for allowing access to social networking sites?

Answer 16

Teen years
Explanation
The American Academy of Pediatrics recommends that preteens not have access to social networks. If teens wish to join social networks, encourage parents to “friend” them, as well as to thoroughly research the site. Internet use should be restricted to a common area, not behind closed doors. Encourage parents to request passwords for all devices, as well as to enforce media-free times (e.g., meals and family gatherings). Encourage parents to engage their children in ongoing discussions of cyberbullying, sexting, family values, and the internet at large.

Question 17

A 6-year-old is brought in by her parents because of concern of seizure disorder. Last night, this was noted:

Intense crying and screaming during her sleep
Diaphoretic
Unresponsive to her parents
Disorientated
Difficult to arouse
No memory of the episode
What is the most likely diagnosis?

Answer 17

Night terrors
Explanation
Night terrors produce a distinct non-REM parasomnia—an abrupt arousal from Stage 3 or 4 slow-wave sleep to near arousal. Most occur during the first 2 hours of sleep or first 1/3 of the night. The child appears to be awake, but is unresponsive, difficult to arouse, unaware of the parent’s presence, and diaphoretic. The child cries intensely and appears disoriented. This is not remembered by the child. Parental reassurance is the best therapy.

Question 18

Maladaptive behaviors (e.g., tantrums, aggression, mood swings, self-injurious behavior) are common in children with autism spectrum disorder.

What medication is usually prescribed to treat these behaviors?

Answer 18

Risperidone
Explanation
Children with maladaptive behaviors typically respond well to risperidone. Risperidone is known to cause increased prolactin levels; therefore, obtain baseline prolactin levels before starting treatment. Risperidone also causes weight gain.

Question 19

Which endocrine abnormality is more common in children with attention deficit hyperactivity disorder (ADHD)?

Answer 19

Answer
Thyroid abnormalities
Explanation
Generally, it is not necessary to perform a thyroid-stimulating hormone test; however, look for signs/symptoms of hypo- or hyperthyroidism. If you see these, pursue a possible thyroid disorder

Question 20

What emotion is commonly expressed in adopted children?

Answer 20

Answer
Grief
Explanation
Even in ideal situations, adopted children often grieve the loss of their biological family. It is helpful for adoptive parents to have ongoing discussions with the child about adoption, answering the child’s questions as they arise with age-appropriate responses. The American Academy of Pediatrics recommends that pediatric health care providers serve their adopted patients as advocates and liaisons to support groups, resources, and social services. Pediatricians are advised to model positive language that reflects permanency about children and their adoptive families. For instance, adoptive families are “real” families; siblings who joined a family through adoption are “real siblings.”

Question 21

A healthy 13-year-old boy:

Missed 5 days of school in the past 2 weeks.
Complained of vague daily stomach discomfort.
Recovered by late morning.
What behavioral issue is this child likely suffering from?

Answer 21

Answer
School refusal
Explanation
School refusal occurs in 1–2% of children and is often associated with vague somatic complaints. The prevalence increases in late middle school/early high school. Family situations (e.g., divorce, domestic violence, illness, death) can contribute to school refusal. Management involves enlisting a team (e.g., parent, teacher, social worker) with the clear goal of getting the child to school. Younger children (9–18 months) often experience separation anxiety when faced with new situations (e.g., day care). This usually resolves by 3 years of age. Management is similar, with parents being encouraged to say a quick, unemotional goodbye.

Question 22

What serious medical condition can occur after someone experiences or witnesses a traumatic event?

Answer 22

Posttraumatic stress disorder (PTSD)
Explanation
Most people recover from traumatic events, but those suffering from PTSD are profoundly affected months to years later. Clinical findings often include irritability, difficulty sleeping, negative thoughts, proneness to anger, and avoidance of situations reminiscent of the trauma. Patients > 6 years of age are treated with trauma-focused psychotherapy, while children ≤ 6 years of age are treated with child-parent psychotherapy. A selective serotonin reuptake inhibitor can be added if needed.

Question 23

What 2 major findings are necessary to make a diagnosis of autism spectrum disorder (ASD)?

Answer 23

1) Impaired social communication/interactions2) Repetitive, restrictive, or stereotypic behaviors/interests
Explanation
The DSM-5 cites 2 major criteria used to diagnose ASD:
Impaired social communication/interaction (e.g., poor eye contact, no age-appropriate peer relationships, will not share achievements with others, lack of emotional reciprocity)
Restrictive, repetitive patterns of activity/interests, often of abnormal intensity (e.g., adherence to specific rituals, stereotyped mannerisms [hand flapping, flipping objects, lining up cars], echolalia)

Question 24

W hich anxiety disorder features an irrational fear of an object or situation?

Answer 24

Answer
Phobia
Explanation
Phobias are irrational fears that are out of proportion to the actual danger, which cause disruption to normal life. Common phobias include the fear of specific animals, insects, heights, flying, germs, and blood. Clinical findings include irritability, restlessness, difficulty concentrating, heightened fight or flight response, and a general feeling of impending doom. Cognitive behavioral therapy is the treatment of choice, though selective serotonin reuptake inhibitors can be added if necessary.

Question 25

2-year-old male with no prior health problems presents with a history of head banging. Most commonly it occurs at bedtime, and occasionally in the middle of the night.

What EEG pattern would you expect to see in this child?

Answer 25

Normal
Explanation
Head banging occurs in 5–15% of children without intellectual challenges. It typically begins at ~ 8–9 months of age, and the behavior usually stops by 4 years of age. Do not order an EEG or an imaging study to evaluate these children. Reassurance is best. This is different in comparison to children with intellectual disabilities or autism, for whom head banging is part of their condition. In these cases, helmets or medications may be required to prevent or lessen head banging

Question 26

What is the best way to manage a sleep problem in a toddler (e.g., waking up in the middle of the night)?

Answer 26

Have a regular bedtime routine
Explanation
Routine is the best way to manage a child; the routine may be to read a book or take a bath. The key is consistency and sticking with it. Verbal reassurance to the child (and to the parent!) eventually wins out. Encourage parents to put their child to bed while the child is drowsy but not yet asleep.

Question 27

A 17-year-old boy presents with chronic cough, phlegm, and wheezing. During the examination he also mentions that he has been having a little trouble at school and his grades have not been great. Physical exam is normal; no rashes are noted.

What illicit drug has he been likely taking on a chronic basis?

Answer 27

Answer
Marijuana
Explanation
Marijuana in the short term causes chronic cough, short-term memory loss, loss of critical judgment, and time perception distortion. Over extended use, it causes decreases in plasma testosterone levels with decreased spermatogenesis and decreased glucose tolerance. Brain function damage caused by marijuana is irreversible.

Cough and wheezing can be associated with inhalant use as well, but there will be perioral eczematous changes as well.

Question 28

A 16-year-old presents to the emergency department after a night of heavy drinking.

What symptoms would you expect in acute alcohol intoxication?

Answer 28

Lower levels: impaired judgment, short-term memory loss; Increased levels: lethargy, disorientation; Extreme levels: death
Explanation
Alcohol use remains alarmingly high among adolescents. The mean age for first use of alcohol is 12.6 years of age. Girls and boys drink alcohol at nearly the same rates. Alcohol acts as a central nervous system depressant. At extreme doses, it acts as a respiratory depressant. In this scenario, be alert to atypical presentations related to co-ingestion of other illicit drugs and to confounding diagnoses (e.g., head trauma) in teens whose altered level of consciousness is out of proportion to their blood alcohol levels. That being said, blood alcohol levels of > 500 mg/dL are usually fatal.

Question 29

What class of drugs is most widely used in the management of attention deficit hyperactivity disorder (ADHD)?

Answer 29

Stimulants (e.g., methylphenidate, dextroamphetamine)
Explanation
The treatment of ADHD is multidisciplinary, involving behavior modification (e.g., positive reinforcement, “extinction” techniques), educational interventions (e.g., star/sticker charts, frequent communication between parent and teacher, preferential seating), and medication. The most common 1st line medications are stimulants (e.g., methylphenidate, dextroamphetamine). They increase the release and inhibit the reuptake of dopamine and norepinephrine. Methylphenidate is available in several different preparations. Amphetamine/dextroamphetamine salts is another frequently prescribed stimulant. Most stimulants are available in short-acting (~ 4 hours) and extended-release (~ 6–10 hours) preparations. Atomoxetine, guanfacine, and clonidine are 2nd line options. Side effects include weight loss, headaches, hypertension, abdominal pain, and insomnia. Stimulants can unmask tics but do not cause them. Frequent follow-up is necessary to monitor blood pressure, weight, and eating/sleeping difficulties.

Question 30

A 12-year-old boy presents with the following behaviors for the past 9 months:

Loses temper often
Actively defies teachers’ and parents’ rules
Annoys people on purpose
Blames others for his behavior
Often is angry and resentful
His behavior has caused a significant drop in his school grades. He has lost friends.

What is the most likely diagnosis?

Answer 30

Oppositional defiant disorder (ODD)
Explanation
ODD occurs in school-age children and adolescents. The disorder usually manifests by 8 years of age. Before puberty, boys are more commonly affected; after puberty, it is equally common in girls and boys. The behavior must persist for ≥ 6 months and not be due to a mood or a psychotic disorder.

Question 31

At what age is separation anxiety usually first noticeable, and when is it especially prominent?

Answer 31

Answer
6 months of age; 9–18 months of age
Explanation
Children with separation anxiety are afraid to leave their parents, are afraid to be with strangers, and may be fearful of new situations. Separation anxiety often manifests at bedtime. It begins to lessen by 3 years of age.

Question 32

A 1-month-old infant seems to have difficulty feeding; he becomes diaphoretic with feeding. Also, he cries excessively.

What is the most likely diagnosis?

Answer 32

Congenital heart disease
Explanation
In this case, suspect some form of congenital heart disease because diaphoresis is uncommon in infants. Look for an anomalous left coronary artery in a “colicky-sounding” infant. The crying could be from the baby having angina!

Question 33

Reports of anabolic steroid use in high school athletes are brought to the attention of the team physician. You are asked to counsel athletes about the adverse effects of androgenic steroids.

What adverse effects would you highlight for this target audience?

Answer 33

Answer
Acne, hirsutism, gynecomastia, testicular atrophy, depression, mania, and rage
Explanation
Androgenic steroids are used by athletes to increase both muscle mass and strength. However, they come with a wide range of adverse effects. Some of these adverse effects are:
Premature closure of growth plates, resulting in shorter-than-expected height
Cardiac, liver, and kidney toxicities
Cardiac arrhythmias and cardiomyopathy
Aggressive behaviors
Gynecomastia

Question 34

What mental health disorder features a physical complaint that has no medical origin?

Answer 34

Psychosomatic disorder
Explanation
Psychosomatic disorders involve medical complaints without a medical basis. They are thought to arise from an impaired adaptation to stress. Symptoms can include headaches, stomachaches, limb pains, and neurologic complaints. Diagnosis requires a thorough history and physical with associated laboratory studies to rule out organic causes. Refer to a mental health professional for psychological testing. Psychosomatic disorders are treated with cognitive-behavioral therapy and medications if comorbidities exist. Conversion disorder is a type of psychosomatic disorder in which there is a loss of voluntary motor or sensory function with no medical cause (pseudoseizures and blindness are examples of conversion disorder).

Question 35

What emotion is commonly evoked in older siblings with the birth of a new baby?

Answer 35

Hostility
Explanation
With the birth of a sibling, older children almost always experience some feelings of hostility. Regression of previously acquired milestones (e.g., regressive toilet training) is common. Others become sad or withdrawn, or they develop aggressive behaviors at home or school. Parents should be open with older children and should encourage involvement in the care of the baby. Fathers (or other close relatives or adults) should also be encouraged to show some extra attention to older children.

Question 36

Following her 8-year-old’s normal wellness exam, a recently divorced mother tells you that her daughter:

Has had a recent decline in schoolwork
Complains frequently of stomachaches
Blames herself for her parents’ separation
What recommendation would you make regarding this child’s behavioral changes?

Answer 36

Referral to a qualified mental health professional
Explanation
Divorce is common in the U.S. Maladjustment disorders often develop from inconsistent parenting styles, change in financial situation, and parental conflict. Be alert for signs of distress in pediatric patients; e.g., depression, withdrawal, somatic complaints, and self-blame. As adults, these individuals are at risk for self-esteem and relationship issues. Common mental health issues the children of divorced parents experience in early and mid-adulthood are depression and anxiety. Early referral to psychiatrists or psychotherapists can be helpful.

Question 37

A 16-year-old boy presents with a 3-week history of:

Decreased appetite
Hypersomnia
Fatigue
Decreased ability to concentrate
Weight loss
Irritability
Diminished interest in playing soccer (his favorite sport)
What should you consider as a possible diagnosis?

Answer 37

Depression
Explanation
When adolescents present with depressed mood or irritability, particularly with diminished interest or lack of pleasure in activities they used to enjoy, think depression. Consider a major depressive disorder (MDD) if, for 2 consecutive weeks, they have ≥ 5 of the following symptoms, with at least 1 of them being #1 or #2: 1) depressed mood/irritability, 2) diminished interest in activities, 3) weight changes and appetite changes, 4) sleep changes, 5) psychomotor agitation or disability, 6) fatigue and energy loss, 7) feelings of worthlessness or excessive guilt, 8) decreased ability to concentrate or think, or 9) recurrent thoughts of self-harm. Always be sure to obtain a thorough history; always assess for self-harm. Think of drug use as well.

Question 38

A 2-month-old presents with:

Crying mainly in the late afternoon
Prolonged crying (3–5 hours a day in the afternoon/evening) and paroxysmal crying (stops and starts abruptly)
Clenched fists, pained expression, and legs over the abdomen during the episodes
No soothing activity
Normal physical exam
What is the most likely diagnosis?

Answer 38

Answer
Colic
Explanation
Colic is common (10–40% of healthy infants). Crying peaks in the later afternoon/evening during the 2nd month of age and wanes in the 3rd or 4th month. The Wessel rule of 3s is a simple way to remember the signs and symptoms of colic: crying for > 3 hours/day for > 3 days/week starting at ~ 3 weeks of age until ~ 3 months of age. If the child is > 4 months of age, colic is highly unlikely. Remember that a corneal abrasion or a tourniquet of hair around the penis or a digit may mimic colic.

Question 39

A healthy 10-year-old boy presents with complete loss of vision following the diagnosis of a brain tumor in his younger sibling. Recent workup includes:

Unremarkable consultation with an ophthalmologist, including dilated exam
Normal CBC, ESR, chemistries, and lipid profile
Unremarkable neuroimaging studies
What is the likely cause of this boy’s vision loss?

Answer 39

Conversion disorder
Explanation
A conversion disorder is a psychosomatic disorder involving a loss of motor or sensory function without a medical cause. A complete history and physical with laboratory workup is essential to rule out an organic cause. With a psychosomatic disorder, the child is relieved of psychological stress by converting it into a physical symptom (often called primary gain). Secondary gain refers to the added benefits of having the physical symptom (e.g., the attention this child receives at a time when his parents have been preoccupied with his sibling). For a suspected psychosomatic disorder, refer to a mental health specialist for psychological testing. Treatment includes cognitive-behavioral therapy and medications if there are comorbidities.

Question 40

You are asked to evaluate a child with possible attention deficit hyperactivity disorder (ADHD).

After history and physical examination are complete, which of the following should you order to confirm your diagnosis: EEG, MRI, both, or none?

Answer 40

None
Explanation
Generally, laboratory testing is not recommended (in particular, EEG and MRI). Standardized assessment scales (Vanderbilt or Conner scales) are most useful, and should be filled out by parents, teachers, caregivers, and others. Evaluation must include a detailed medical, family, and social history, along with a complete physical examination. By definition, symptoms must be present in ≥ 2 settings (e.g., school, home, day care).

Question 41

A teenager is brought to the emergency department by police because of erratic and aggressive behavior. His friends told police that he tried some lysergic acid diethylamide (LSD).

Is this behavior consistent with LSD use?

Answer 41

Yes
Explanation
Hallucinogens are a category of substances that alter sensory perception, thought and emotions. Although some can be snorted, smoked, or injected, most are typically ingested orally. Symptoms of acute intoxication include hallucinations, “out-of-body” experiences, delusions, disorientation, and disinhibition. LSD is a very potent hallucinogen. Altered sensory perception and rapid emotional shifts can occur. Individuals can become delusional, paranoid, and psychotic. Late complications can include flashbacks.

Question 42

What are the stages of grief that adolescents experience with the death of a close family member?

Answer 42

Denial, anger, bargaining, depression, and acceptance
Explanation
The death of a close family member is one of the most stressful events that a child can experience. Young children can have eating, sleeping, speech, and bowel/bladder disturbances. School-age children may experience depression, behavioral issues, and an obsession with their own health. Adolescents, like adults, experience the 5 stages of grief: denial, anger, bargaining, depression, and acceptance.

The primary care physician can play a significant role by coordinating referrals to counselors and bereavement support groups for both the patient and family members as needed. It is important to identify patients whose grief reactions are outside normal parameters, and who need more specialized treatment. Studies have shown that bereaved children have a higher incidence of adult psychiatric disorders compared to the general population.

Question 43

A 17-year-old boy presents with:

Ataxia
Euphoria
Abusive language uncharacteristic for him
Thrashing out and difficult to control because, he says, people are trying to “get him”
What illicit drug did he likely get exposed to?

Answer 43

Phencyclidine (PCP)
Explanation
PCP causes cramping, diarrhea, and hematemesis and the neurologic effects of euphoria, nystagmus, ataxia, and hallucination. High doses result in frank psychosis and verbally abusive language. Even higher doses can result in cardiac arrhythmia and seizures.

Question 44

What type of disorder is obsessive-compulsive disorder (OCD)?

Answer 44

Neurobiological
Explanation
OCD is thought to be a neurobiological disorder; there is also a familial component. Environmental factors, such as infections, are also suggested as potential triggers for OCD, but more research is needed. OCD affects up to 3% of children and adolescents; 75% of these children experience comorbid diagnoses. The mean age of onset of OCD in the pediatric population is ~ 10 years of age. Boys are more commonly affected than girls; boys tend to have an earlier age of onset.

Question 45

What is the most common obsessive-compulsive disorder (OCD) “ritual” in childhood?

Answer 45

Repetitive cleaning and washing
Explanation
OCD affects up to 3% of children and adolescents; 75% of these children experience comorbid diagnoses. The mean age of onset in the pediatric population is ~ 10 years. The most common ritual (compulsion) is repeatedly cleaning and washing, including showering, hand washing, and tooth brushing.

Other common OCD rituals are:
Going in and out of doors
Rereading
Rechecking that stove and appliances are off
Rechecking the alarm clock
Counting, ordering, and arranging objects

Question 46

I n newborns, which type of sleep occurs at the onset of sleep?

Answer 46

REM sleep
Explanation
For newborns < 1 month of age, active REM-like sleep begins at the onset of sleep. Older children have nearly 75% non-REM sleep because non-REM sleep begins before REM sleep kicks in.

Question 47

An otherwise healthy 10-year-old boy presents for a behavior consult with:

3-year history of eye blinking/facial twitching
1-year history of vocal barks
Recent progression to foul utterances
What is the most likely diagnosis?

Answer 47

Tourette syndrome
Explanation
Tourette syndrome is the most severe tic disorder. DSM-5-TR diagnostic criteria include multiple motor/vocal tics present for at least 1 year, no tic-free interval > 3 months, onset prior to 18 years of age, and lack of underlying medical cause. The average age of onset is ~ 7 years and often peaks in severity between 10 and 12 years of age. After that time, the intensity and frequency of the tics usually decrease. Per DSM-5-TR, the risk factors for developing Tourette syndrome are a combination of environmental, genetic, and physiological factors. There is a 70–85% rate of heritability. A subset of patients have mutations involving the SLITRK1 gene of unclear clinical significance. Of note, stimulants used to treat attention deficit hyperactivity disorder (ADHD) often unmask tics but do not cause them. A tic disorder is not a contraindication to stimulant therapy for ADHD as the effect of medication on tics is unpredictable.

Question 48

Which mineral deficiency has been associated with trichotillomania (hair pulling)?

Answer 48

Iron deficiency
Explanation
Generally, trichotillomania falls within the realm of obsessive-compulsive disorders. In some cases, it has been associated with iron-deficiency anemia.

Question 49

What is the maximum amount of screen time currently recommended for a child 3 years of age?

Answer 49

1 hour per day
Explanation
The American Academy of Pediatrics (AAP) recommends just 1 hour per day of high-quality programming for children 2–5 years of age.

The AAP recommends no screen time for children < 18 months of age. For children 18–24 months of age, watch digital media with them because they learn from watching and talking with you. For children > 6 years of age, place consistent limits on the time spent using the media and the types of media. Make sure the media does not take the place of adequate sleep (8–12 hours per day, depending on age), physical activity (1 hour per day), and other behaviors essential to health. Excessive media use has been linked to behavioral problems, obesity, aggression, sleep issues, and poor school performance. Television should not be allowed in a child’s room, nor should internet access. The AAP recommends that preteens not have access to social media.

Question 50

A 13-year-old boy is diagnosed with attention deficit hyperactivity disorder (ADHD). He is placed on stimulant medication.

When children with ADHD are placed on stimulant medication, what disorder may be unmasked?

Answer 50

Answer
Tic disorder
Explanation
Stimulant medication used to treat ADHD may unmask (but not cause) a tic disorder. ADHD and tics are commonly comorbid conditions; use of methylphenidate generally improves the ADHD without worsening the tic disorder. Discontinuation of the stimulant is only recommended if the tic becomes more of a problem than the ADHD.

Question 51

A teenager presents with a chronic cough. He smokes about 1–2 packs of cigarettes per day; he has been smoking for the past 3 years.

If you advise him to stop smoking abruptly on his own, what symptoms would you expect?

Answer 51

Answer
Dysphoria, sleep disturbance, irritability, anxiety, restlessness, increased appetite
Explanation
Abrupt discontinuance of cigarette smoking in an established smoker is called nicotine withdrawal syndrome. Use nicotine replacement (e.g., nicotine patch, gum) and behavioral counseling to manage withdrawal symptoms

Question 52

How soon after foster care placement is an initial health screening needed?

Answer 52

Within 72 hours
Explanation
Children in foster care have a high incidence of chronic medical, emotional, and developmental issues. Many of these children have been the victims of abuse and/or neglect; physical and mental health are further impacted by separation from biological families and the uncertainty of foster care. The initial health screening is required to address any immediate physical or mental issues. A more comprehensive exam is performed within the 1st month of placement to form a plan for each physical, mental, developmental, and educational issue identified. A follow-up visit occurs 1–2 months later. Subsequently, monthly visits are scheduled until 6 months of age, every 3 months between 6 and 24 months of age, and every 6 months between 2 and 21 years of age. Birth parents still have legal guardianship; foster parents cannot consent to immunizations or procedures. Consent must be obtained from the biological parents or social services, as needed

Question 53

A 20-month-old boy presents for his wellness exam with:

No intelligible words
Poor eye contact
Persistent rocking/arm flapping behavior
The mother has concerns regarding his recent measles, mumps, rubella (MMR) vaccine.

What is the most likely diagnosis?

Answer 53

Autism spectrum disorder (ASD)
Explanation
Autism spectrum disorder (ASD) is a biologically based, life-long, neurodevelopmental disorder characterized by impaired social communication and repetitive and restricted behaviors and interests. It is thought to be caused by genetically altered brain development resulting in the neurobehavioral phenotype. In the U.S., 1 in 68 children is affected, with a predominance among men. ASD is more common in certain genetic conditions (e.g., tuberous sclerosis, fragile X syndrome, untreated phenylketonuria). Overwhelming research evidence supports no causal relationship with vaccines. Hyper- or hyposensitivity to sensory input is another core symptom of ASD. Specific sensory sensitivity to foods, clothing, clothing tags, and certain surfaces is common.