Behavioral Medicine & Substance Abuse

Question 1

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. Her mother is worried that she had a seizure because she had some tonic-clonic movements as well.

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

Answer 1

Reassurance

Breath-holding spells are benign—there are no long-term effects or brain injury. There are 2 forms of breath-holding temper tantrums:

1. The cyanotic form, in which the face turns blue until breathing returns
2. 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 one subsequent cry.

Question 2

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

What adverse effects would you highlight for this target audience?

Answer 2

Acne, Hirsutism, Gynecomastia, Testicular Atrophy, Azoospermia, Depression, Mania, Rage

Anabolic androgenic steroids are used by athletes to increase both muscle mass and strength. However, they come with a wide range of adverse effects. In addition to those listed above, some of them are:

• Premature closure of growth plates resulting in shorter-than-expected height
• Cardiac, liver, and kidney toxicities
• Cardiac arrhythmias and cardiomyopathy
• Hepatic adenomas and carcinomas
• Cholemic nephrosis related to hyperbilirubinemia

If all this is not enough, suicidal ideation and suicides have been associated with withdrawal.

Question 3

A 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 3

Normal

Head banging occurs in 5–15% of “normal” children. 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 from 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 the banging.

Question 4

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 4

Tourette Syndrome

Tourette syndrome is the most severe tic disorder. DSM-5 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. Most cases are successfully managed with cognitive behavioral therapy, though if comorbidities exist (e.g., ADHD, obsessive compulsive disorder [OCD], oppositional defiant disorder [ODD]), tics often improve with treating the underlying condition. Of note, stimulants used to treat ADHD often unmask tics but do not cause them.

Question 5

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

What medication is usually prescribed to treat these behaviors?

Answer 5

Risperidone

Children with maladaptive behaviors typically respond well to risperidone. Risperidone is known to cause increased prolactin levels; therefore, get baseline prolactin levels before starting treatment.

Question 6

A 13-year-old boy is diagnosed with ADHD. He is placed on stimulant medication.

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

Answer 6

Tic Disorder

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

Question 7

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

Answer 7

Have a Regular Bedtime Routine

The routine may be to read a book, take a bath, etc. 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 children to bed while they are awake, drowsy but not yet asleep.

Question 8

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

How would you manage this patient?

Answer 8

Cooling Blankets, Larozepam or Diazepam.

Methamphetamine (a.k.a. “ice”) can be administered by mouth, through inhalation (smoking), through mucous membranes, or by injection. 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.

Behavioral findings include agitation and delusional behaviors. These can be treated with haloperidol or droperidol.

Question 9

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

• Has had a recent decline in schoolwork
• Frequently complains of stomachaches
• Blames herself for her parents’ separation

What recommendation would you have regarding this child’s behavioral changes?

Answer 9

Referral to a Qualified Mental Health Professional

Divorce is common in the United States. Maladjustment disorders often develop from inconsistent parenting styles, change in financial situation, and parental conflict. Be alert for signs of distress in your pediatric patients, such as depression, withdrawal, somatic complaints, and self-blame. As adults, these individuals are at risk for self-esteem and relationship issues of their own. Early referral to psychiatrists or psychotherapists can be helpful.

Question 10

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

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

Answer 10

Opiates (Heroin)

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, but the patient should be managed in a professional setting.

Question 11

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

What is the most likely diagnosis?

Answer 11

Congenital Heart Disease

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 12

A 17-year-old boy presents with:

• Ataxia
• Euphoria
• Verbal 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 12

PCP (Phencyclidine)

PCP causes the GI effects cramping, diarrhea, and hematemesis and the neurologic effects euphoria, nystagmus, ataxia, and hallucination. Higher doses result in frank psychosis and verbal abusive language. Even higher doses can result in cardiac arrhythmia and seizures.

Question 13

A 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
• Experienced facial cyanosis until breathing resumed

What caused this child’s apnea?

Answer 13

Breath-Holding Spell (Cyanotic Type)

Breath-holding spells (cyanotic type) are often associated with temper tantrums. Though frightening, they are benign. Temper tantrums are common in the 2- to 4-year-old age group, with 20% of 2-year-olds having 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, though once a tantrum has begun, it’s best to ignore the behavior.

Question 14

An adolescent presents for counseling because of drug dependence.

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

Answer 14

Household Drug Use (Especially by Parents!); Peer Group Drug Use; Untreated ADHD

The consequences of substance abuse can be devastating, frequently leading to accidents, injuries, and death. Associated high-risk sexual behaviors can result in unwanted pregnancy and STIs (including HIV). Continued abuse of substances can result in fetal anomalies (e.g., fetal alcohol syndrome). Substance abuse is linked to delinquency and crime. Long-term abuse has been associated with neuropsychiatric impairment.

Question 15

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 MMR vaccine.

What is the most likely diagnosis?

Answer 15

Autism Spectrum Disorder (ASD)

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 are affected, with a male predominance. ASD is more common in certain genetic conditions (e.g., TB, fragile X syndrome, untreated PKU). Overwhelming research evidence supports no causal relationship with vaccines.

Question 16

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

Answer 16

Anxiety Disorder

Younger children often fear things like separation from a parent, animals, heights, and the sight of blood. Adolescents have the added fears of academic failure and the lack of peer approval. What separates normal situational anxiety or fear from anxiety disorder is that the latter involves the presence of restlessness, irritability, difficulty with concentration, sleep disturbance, muscle tension, and fatigue that interferes with daily life. Treat anxiety disorders with cognitive behavioral therapy (CBT). If there is no improvement, a selective serotonin reuptake inhibitor (SSRI) can be added. Comorbidity exists with ADHD, oppositional defiant disorder (ODD), and depression.

Question 17

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 17

Hypotension, Cutaneous Flushing Followed by Vasoconstriction, Tachycardia, Inverted T Waves and ST Depression

Huffing refers to the inhalation of fumes or vapors from a closed container such as a paper bag, balloon, or soda can. Inhalants are abused for their psychoactive properties. They tend to be short-acting, so dosing tends to be repeated in order to prolong the euphoria.

Methemoglobinemia has been reported with amyl nitrate. When this occurs, the SaO₂ is decreased. Treatment is supportive.

Question 18

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

Answer 18

Denial, Anger, Bargaining, Depression, and Acceptance

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.

Question 19

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 19

Depression

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 get a thorough history and think of drug use as well.

Question 20

A mother brings in her 8-year-old child with a history of 2 prior admissions for bacteremia—one with E. coli and the 2^nd with a mixture of organisms, including E. coli and Serratia. The mother is a nurse in another hospital.

The child now presents with the following, fever, hypotension, and shock.

Previous workup for immune dysfunction was negative. The mother seems happy that the child is ill again and is excited to be coming into the hospital.

What diagnosis should be entertained at this point?

Answer 20

Factitious Disorder Imposed by Another (Formerly Munchausen Syndrome by Proxy)

Factitious disorder imposed by 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 the one involved, and she is commonly 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—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 21

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

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

Answer 21

Alcohol

Most teenagers have tried alcohol by the time they are seniors in high school. 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.

Impaired judgement, 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 22

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

Answer 22

Iron Deficiency

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

Question 23

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 ophthalmology consult, 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 23

Conversion Disorder

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). Treatment includes cognitive behavioral therapy (CBT) and medications if there are comorbidities.

Question 24

You are asked to evaluate a child with possible ADHD.

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

Answer 24

None

Generally, laboratory testing is not recommended (EEG and MRI in particular). Standardized assessment scales are most useful and should be filled out by parents, schools, afterschool providers, etc.

Question 25

A 12-year-old boy presents with repetitive, persistent (9 months now) 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 behavior. The behaviors occur at home, school, and in the community.

What is the most likely diagnosis?

Answer 25

Conduct Disorder

Conduct disorder is a complex, multifactorial disorder. Generally, think of it in kids who have repetitive, persistent (> 6 months) behaviors that violate others’ rights or destroy others’ property. In addition, drug use and instigation of sexual abuse are associated with this disorder.

Question 26

Which endocrine abnormality is more common in children with ADHD?

Answer 26

Thyroid Abnormalities

Generally, it is not necessary to perform a thyroid stimulating hormone (TSH) test, but look for signs/symptoms of hypo- or hyperthyroidism. If you see these, pursue a possible thyroid disorder.

Question 27

Do nightmares occur during REM or non-REM sleep?

Answer 27

REM Sleep

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 28

A 2-month-old presents with:

• Crying mainly in the late afternoon
• Crying is prolonged (3–5 hours a day in the afternoon/evening) and paroxysmal (stops and starts abruptly).
• During the episodes, the infant has clenched fists, pained expression, and legs over the abdomen.
• Nothing soothes the baby.
• Normal physical exam

What is the most likely diagnosis?

Answer 28

Colic

Colic is common (40%). 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 around 3 weeks of age until about 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 29

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

Answer 29

Psychosomatic Disorder

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. Once you suspect a psychosomatic disorder, refer to a mental health professional for psychological testing. Psychosomatic disorders are treated with cognitive behavioral therapy (CBT) and medications if comorbidities exist.

Question 30

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

• She missed school 3 times last month to go to the mall.
• Her parents were unaware of her absence.
• Her family life is stable, without major disruptions.

What is the likely cause of this girl’s absenteeism?

Answer 30

Truancy

Truancy is a child’s absence from school without his or her 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 and is often associated with anxiety and social phobia. Parents are aware of the absenteeism and 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 31

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

Answer 31

Post-Traumatic Stress Disorder (PTSD)

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. Individuals > 6 years of age are treated with trauma-focused psychotherapy, while children ≤ 6 years of age are treated with child-parent psychotherapy. SSRIs can be added if necessary.

Question 32

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 32

Yes

LSD is a very potent hallucinogen. Altered sensory perception and rapid emotional shifts with impulsivity can occur. Individuals can become delusional, paranoid, and psychotic. Late complications can include flashbacks.

Question 33

In infants, which type of sleep occurs at the onset of sleep?

Answer 33

REM Sleep

For newborns < 1 month of age, active REM-like sleep begins at the onset of sleep, but in older children, non-REM sleep begins before REM sleep kicks in. Infants have a higher proportion of REM sleep, but older children have nearly 75% non-REM sleep.

Question 34

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

Answer 34

Neurobiological

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. Boys are more commonly affected than girls and tend to have an earlier age of onset.

Question 35

Which anxiety disorder features an irrational fear of an object or situation?

Answer 35

Phobia

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 (CBT) is the treatment of choice, though SSRIs can be added if necessary.

Question 36

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

Answer 36

Hostility

With the birth of a sibling, older children almost always experience some feelings of hostility. Regression of previously acquired milestones is common as well. 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 shower some extra attention on older children during this difficult time.

Question 37

An adolescent boy presents with:

• Dizziness
• Dilated pupils
• Says he “sees smells” and “hears colors”
• Delusions that he is someone else

What illicit drug did he likely take?

Answer 37

LSD (Lysergic Acid Diethylamide)

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

Question 38

What class of drugs is most widely used in the management of ADHD?

Answer 38

Stimulants (e.g., Methylphenidate and Dextroamphetamine)

The treatment of ADHD is multidisciplinary, involving behavior modification (e.g., “time-outs,” positive reinforcement, “extinction” techniques), educational interventions (e.g., star/sticker charts, frequent communication between parent and teacher, preferential seating), and medication. The most common 1^st line medications are stimulants (e.g., methylphenidate, dextroamphetamine), with atomoxetine, guanfacine, and clonidine being 2^nd line options. Most stimulants have extended-release preparations. Side effects include weight loss, headaches, hypertension, abdominal pain, and sleep difficulties. Stimulants can unmask tics but do not cause them. Frequent follow-up is necessary to monitor blood pressure, weight, and eating/sleeping difficulties.

Question 39

An 18-year-old male presents with chronic cough, phlegm, and wheezing. During the examination he also mentions that he has been having a little trouble at school and that his grades haven’t been great.

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

Answer 39

Marijuana

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.

Question 40

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

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

Answer 40

Dysphoria, Sleep Disturbance, Irritability, Anxiety, Restlessness, and Increased Appetite

Abrupt discontinuance of cigarette smoking in an established smoker is called nicotine withdrawal syndrome. Use nicotine replacement (e.g., nicotine patch or gum) and behavioral counseling to manage withdrawal symptoms.

Question 41

What is the maximum amount of screen time currently recommended for a child > 2 years of age?

Answer 41

≤ 2 Hours per Day

The AAP recommends ≤ 2 hours of recreational screen time daily for children ≥ 2 years of age and no screen time for children < 2 years of age. 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 Internet should be accessed in a common area of the home, not behind closed doors. The AAP recommends that preteens not have access to social media. Once children are old enough to access social media sites, encourage parents to “friend” their teens and to research all new apps. Encourage parents to request all passwords and to enforce media-free times such as meals and family gatherings. Encourage parents to have discussions regarding cyberbullying, family values, and the Internet at large.

Question 42

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

Answer 42

1. Impaired Social Communication/Interactions
2. Repetitive, Restrictive, or Stereotypic Behaviors or Interests

The DSM-5 cites 2 major criteria used to diagnose ASD:

1. Impaired social communication/interaction (e.g., poor eye contact, no age-appropriate peer relationships, will not share achievements with others, lack of emotional reciprocity)
2. 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 43

What does thumb sucking that persists into adolescence possibly indicate?

Answer 43

Psychological Problems

Thumb sucking peaks between 18 and 21 months of age, and 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 44

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

Answer 44

6 Months of Age; 9–18 Months of Age

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 45

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

Answer 45

Within 72 Hours

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 thereafter between 2 and 21 years of age. Of note: Birth parents still have legal guardianship; therefore, foster parents cannot consent to immunizations or procedures. Consent must be obtained from the biological parents or Social Services, as needed.

Question 46

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, disoriented
• Difficult to arouse
• She does not remember the episode.

What is the most likely diagnosis?

Answer 46

Night Terrors

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. The child appears to be awake but is unresponsive, difficult to arouse, unaware of the parent’s presence, cries intensely, is diaphoretic, and appears disoriented. This is not remembered by the child. Parental reassurance is the best therapy.

Question 47

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 47

School Refusal

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 and is often associated with anxiety disorders and social phobias. Family situations, such as divorce, domestic violence, illness, and 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 48

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

Answer 48

Teen Years

The AAP 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 such as meals and family gatherings. Encourage parents to engage their children in ongoing discussions of cyberbullying, sexting, family values, and the Internet at large.

Question 49

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

Answer 49

Bipolar Disorder

Bipolar disorder is characterized by alternating periods of depression and mania. Depressive symptoms include fatigue, decreased energy, depressed mood, and anhedonia, while manic symptoms include intense energy, sleeplessness, pressured speech, grandiosity, and risk-taking behaviors. Risk factors include a family history of bipolar disease, 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) and a selective serotonin reuptake inhibitor (SSRI) as needed.

Question 50

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

• Loses temper often
• Actively defies teachers’ and parents’ rules
• Annoys people on purpose
• Blames others for his behavior
• Often angry and resentful
• His behavior has caused a significant drop in his school grades, and he has lost friends.
• What is the most likely diagnosis?

Answer 50

Oppositional Defiant Disorder (ODD)

ODD occurs in school-age and adolescent children. 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 51

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 51

Lower Levels: Impaired Judgement, Short-Term Memory Loss;

Increased Levels: Lethargy, Disorientation;

Extreme Doses: Death

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 coingestions 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 52

A teenager presents to the emergency department with an acute traumatic fracture and is given a 1-week supply of pain medication. She returns to the emergency department later that night with slow, sonorous respirations; lethargy; and confusion. On physical examination she is hypothermic and bradycardic with pinpoint pupils and decreased bowel sounds.

After initial management based on airway, breathing, and circulation, what is the most appropriate drug to administer to this patient?

Answer 52

Naloxone

This patient illustrates the classic toxidrome for acute opioid intoxication. Naloxone is an opioid antagonist and is the preferred treatment for an acute overdose.

Because opioids can cause respiratory depression and apnea, your initial assessment focuses on the ABCs: Airway, Breathing, and Circulation. You should be prepared to maintain an airway and support ventilation.

Question 53

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

Answer 53

Repetitive Cleaning and Washing

This ritual (compulsion) includes repeatedly showering, hand washing, and toothbrushing. Other common OCD rituals:

• Going in and out of doors
• Rereading
• Rechecking that stove and appliances are off
• Rechecking the alarm clock
• Counting, ordering, and arranging objects

Question 54

What emotion is commonly expressed in adopted children?

Answer 54

Grief

Even in an ideal situation, adopted children often grieve the loss of their biological family. It’s helpful for the adoptive parents to have ongoing discussions about adoption, answering the child’s questions as they arise with age-appropriate responses. The AAP recommends that pediatric health care providers serve their adopted patients as advocates and liaisons to support groups, resources, and social services.