Child psychiatry and learning disability

Question 1

All of the following are features of Down’s syndrome except
A. Increased cardiac mortality and morbidity
B. Lax ligaments
C. Wide gap between fi rst and second toes
D. Increased incidence of leukaemia
E. Delayed puberty

Answer 1

E. One of the most common causes of death in Down’s syndrome is congenital heart disease.
Common phenotypic features seen in children with Down’s syndrome include brachycephaly,
broad hands, single palmar crease, epicanthal folds, clinodactyly of fi fth fi nger, fl at nasal bridge, and
wide gap between fi rst and second toes, hypotonia with lax ligaments, short stature, and mental
retardation. In addition, children may have congenital heart defects such as ventricular septal
defect, duodenal atresia at birth, and increased incidence of leukaemia in childhood. Atlantoaxial
subluxation may occur in children with Down’s syndrome, leading to spinal cord compression.
The signs and symptoms of hypothyroidism can develop slowly over time and can be diffi cult
to discriminate from those of Down’s syndrome itself. No differences have been found in terms
of age of onset of the physical features of puberty in adolescent girls and boys with Down’s
syndrome compared with general population trends. In men, reproductive capacity appears to be
diminished, but women with Down’s syndrome are able to bear children

Question 2

Which of the following is false with regard to behavioural and psychiatric
disorders associated with Down’s syndrome?
A. Rates of non-organic psychiatric disorders are higher in Down’s syndrome than in
learning disability due to other causes
B. Autism has a signifi cant association with Down’s syndrome
C. Seizures are a frequent clinical feature of Alzheimer’s dementia in those with Down’s
syndrome
D. Medical conditions may underlie psychiatric presentations
E. Most patients have a placid temperament

Answer 2

A. Children with Down’s syndrome are known to be gentle, mild mannered, and easygoing.
It is reported that emotional and behavioural problems are less frequent than other forms of
learning disabilities. Medical causes must be ruled out before considering a de novo psychiatric
explanation for behavioural and emotional problems. The dual diagnoses of Down’s syndrome
and autism has been recognized for some time, with recent reports quoting 7% of Down’s
syndrome children having autism. Puri et al. (2001) showed in a study of 68 adults with Down’s
syndrome that individuals aged over 45 with a history of seizures were signifi cantly more likely
to develop Alzheimer’s dementia; nearly 84% of demented individuals with Down’s syndrome
developed seizures. This is far higher than the rate of seizures found in Alzheimer’s dementia
without Down’s syndrome (10%) and Down’s syndrome without dementia (8%). Early-onset
seizures in Down’s syndrome seem to be unrelated to Alzheimer’s type of pathology.

Question 3

Classifi cation of mental retardation into ‘subcultural’ and ‘pathological’
subtypes was fi rst described by
A. EO Lewis
B. Henry Maudsley
C. Kraepelin
D. Morel
E. Kanner

Answer 3

A. EO Lewis suggested the distinction between subcultural learning disability and biological
learning disability in 1933. ‘Subcultural mental handicap’ refers to the lower extreme variant of
IQ distribution seen in the population. The biological or pathological type is seen to be evenly
distributed across all social classes, whereas the subcultural type is often seen in social class V
and associated with mild rather than profound disability. Kraeplin is associated with dementia
praecox, and French psychiatrist Benoit Morel is associated with the theory of degeneration in
schizophrenia. Kanner is associated with infantile autism.

Question 4

All of the following are true with regard to foetal alcohol syndrome except
A. Decreased cranial size at birth
B. Agenesis of the corpus callosum
C. Neurosensory hearing loss
D. Poor eye–hand coordination
E. Congenital cataract

Answer 4

E. The diagnostic criteria for foetal alcohol syndrome includes confirmed maternal alcohol
exposure in addition to evidence of characteristic facial anomalies such as short palpebral
fissures and abnormalities in the premaxillary zone, including flat upper lip, cleft palate,
flattened philtrum, and flat midface. Evidence of growth retardation includes low birthweight
for gestational age or decelerating weight gain over time not due to undernutrition. Features
suggestive of neurodevelopmental abnormalities such as decreased cranial size at birth, structural
brain abnormalities (e.g. microcephaly, partial or complete agenesis of the corpus callosum,
cerebellar hypoplasia), and neurological signs (impaired fi ne motor skills, neurosensory hearing
loss, poor tandem gait, poor eye–hand coordination) are also included in the diagnostic criteria.
Congenital cataract is not suggestive of foetal alcohol syndrome; in infants with cataract, other
explanations for developmental problems such as toxoplasmosis, congenital rubella, or metabolic
syndromes must be sought

Question 5

A subcultural rather than neuropathological explanation for learning
disability is supported by which of the following?
A. Even distribution of learning disability across different socioeconomic groups of the
population
B. Existence of a profound degree of learning disability
C. Learning disability in other members of the family
D. Facial dysmorphic features
E. Signifi cant problems with adaptive functioning

Answer 5

C. Subcultural learning disability refers to the lower extreme variant of IQ distribution
seen in the population and it often seen in social class V and associated with mild rather than
profound disability. Many family members of individuals with subcultural learning disability may
also have borderline IQ, probably due to the effects of shared environment and social infl uences.
In contrast, the biological or pathological type is seen to be evenly distributed across all social
classes. Dysmophic features are more likely to be seen in those with a biological cause of learning
disability with syndromic presentation being noted. Subcultural learning disability suggests the
concept of a psychosocial causation (e.g. physical and emotional neglect). This is controversial.

Question 6

A 6-year-old boy has autistic features, hyperactivity, and inattention. He is
noted to have frequent self-injurious head banging and nail pulling. There is
a history of both nocturnal and diurnal enuresis. He has an IQ in the range
of moderate learning disability. He has normal uric acid levels in his serum.
The most likely cause is
A. Trisomy 21
B. 7q11 deletion in the elastin gene
C. 17p11 microdeletion
D. Hypoxanthine guanine phosphoribosyltransferase defi ciency
E. Trisomy 13

Answer 6

C. Smith–Magenis syndrome has a prevalence of 1: 500 000. It is caused by a microdeletion
on the short arm of chromosome 17p11·2. The degree of intellectual impairment is usually
variable. The phenotype includes bradydactyly, a broad, fl at face, hoarse voice, and a characteristic
fl eshy upper lip, although these features may be very subtle. Prominent autistic features,
hyperactivity (in 75%), inattention, and self-injury (in 70%) such as head banging, nail pulling, and
hand biting, are seen. Nocturnal and diurnal enuresis may also be present. Sleep is characterized
by reduced or absent REM phase. Trisomy 21 refers to Down’s syndrome. 7q11 deletion in the
elastin gene can result in Williams syndrome, which is characterized by hyperactivity, ‘cocktail
party speech’, and supravalvular aortic stenosis. Hypoxanthine guanine phosphoribosyltransferase
defi ciency can result in Lesch Nyhan syndrome with severe self-mutilation, aggression, and
hyperuricaemia. Trisomy 13 syndrome is also known as Patau’s syndrome and can be of three
types: full trisomy, mosaic pattern type, and translocation type. All survivors have profound
mental retardation.

Question 7

The most powerful predictor of overall functional outcome in children with
autism is given by
A. Family history of autism
B. Autistic symptom count
C. Presence of soft neurological signs
D. IQ level
E. Non-verbal skills

Answer 7

D. Autism is a disorder with lifelong disability. About 70% of autistic individuals have an IQ
in the learning disability range. In autism, IQ has been shown to be the most powerful predictor
of outcome. A distinctive cognitive profi le characterized by strong visuospatial skills and poor
abstract ability has been noted. A small proportion of autistic children may have islets of special
abilities and are dubbed as ‘autistic savants’. The presence of communicative speech by the age of
5 years is another important predictor of positive outcome.
Lask B, Taylor S, Nunn K, eds. Practical Child Psychiatry: The Clinician’s

Question 8

Which of the following groups of school children develops a higher
prevalence of psychopathology as adults than the others listed?
A. Victims of bullying
B. Perpetrators of bullying
C. Children who do not bully and are not victimized by others
D. Children who frequently bully others and get victimized by others
E. Children who report bullying to teachers and authorities

Answer 8

D. In a sample of more than 2500 boys born in 1981, details of bullying and victimization
were gathered when the boys were 8 years old. Between the ages of 18 and 23, information
about psychiatric disorders was collected from a registry. The boys could be classifi ed into those
who bully others, those who are frequently victimized, and those who bully others and are
victimized frequently. Frequent bullying-only status predicted antisocial personality and substance
abuse; frequent victimization-only status predicted anxiety disorder, whereas frequent bully–
victim status predicted antisocial personality and anxiety disorder. Frequent bully–victims were at
particular risk of adverse long-term outcomes compared with either pure bullies or pure victims.

Question 9

The most common known inherited cause of learning disability is
A. Down’s syndrome
B. Fragile X syndrome
C. Cri du chat syndrome
D. Galactosaemia
E. Hypothyroidism

Answer 9

B. Fragile X syndrome is the most common known inherited cause of learning disability.
It affects 1:3600 boys and 1:6000 girls. Thirty per cent of individuals affected by fragile X have
autistic features. Nearly 20% have epilepsy too. 1 in 300 women and 1 in 800 men are carriers of
fragile X mutation. Although Down’s syndrome is a more common cause of learning disability, it is
mostly sporadic and not inherited in the strict sense

Question 10

The point prevalence of schizophrenia in people with learning disability is
A. 1%
B. 20%
C. 3%
D. 15%
E. 10%

Answer 10

C. The point prevalence of schizophrenia is estimated to be between 3% and 4% in the
learning-disabled population compared with 1% in the general population. Schizophrenia cannot
be reliably diagnosed below an IQ of approximately 45. Often in clinical practice, if there is
evidence of delusions or hallucinations in those with profound learning disability, a diagnosis of
psychosis not otherwise specifi ed is used. Despite this the rate of schizophrenia is signifi cantly
higher among the population with learning disability. This increase is seen despite the overall
rate of psychiatric illness among adults with mild to moderate learning disability being similar
to that in the general adult population without learning disability. The reason for this increased
comorbidity is unclear, and common underlying brain damage that could cause both learning
disability and schizophrenia cannot be ruled out.

Question 11

An 18-year-old man with learning disability has ectopia lentis, fair hair, long
thin limbs, and osteoporosis. The most likely diagnosis is
A. Phenylketonuria
B. Homocystinuria
C. Marfan syndrome
D. Tay Sach’s disease
E. Fragile X syndrome

Answer 11

B. Homocystinuria is a metabolic disorder characterized by an increased blood and urine
concentration of amino acid homocysteine. Clinical features resemble Marfan syndrome; patients
have ectopia lentis, chest and spinal deformities similar to Marfan syndrome. But changes in hair
colour, osteoporosis, arterial and venous thrombosis, and learning disabilities are generally absent
in patients with Marfan syndrome.

Question 12

The social approach of providing a pattern of life as ordinary as possible for
the learning disabled population is called
A. Community rehabilitation
B. Eugenics
C. Normalization
D. Reality orientation
E. Standardization

Answer 12

C. In the past, learning disability has been a cause for social rejection, with prejudiced
labels such as ‘degeneracy’ associated with it. The so-called degenerates were isolated
from the community, leading to the establishment of large mental institutions. The principle
of normalization is seen by many as a reaction to the dehumanizing policies of the past.
Normalization promotes independence and autonomy while making it possible for people with
learning disabilities to have an ordinary life with the same choices and opportunities as everyone
else. This shifts the focus from ‘disability’ to ‘differences in ability’.

Question 13

The proportion of the learning disabled population with an IQ in the range
50–70 is
A. 10%
B. 2%
C. 4%
D. 85%
E. 40%

Answer 13

D. Nearly 85% of those with learning disability have an IQ in the range 50–70 (mild learning
disability). Of the rest, nearly 10% have moderate learning disability with an IQ in the range
35–50 and around 5% have an IQ in the severe/profound learning disability range (less than 35).

Question 14

A landmark epidemiological study in child psychiatry is the Isle of Wight
study in the UK. What was the nature of the original sample fi rst studied?
A. A sub-sample of all children aged 5–13
B. Every other child aged 5–17
C. A sub-sample of all children aged 9–15
D. All children aged 9–11
E. Every other child aged 9–12

Answer 14

D. Major epidemiological work in child psychiatry started with the Isle of Wight surveys
between 1964 and 1974. The Isle of Wight surveys had a two-phase design, with a systematic
questionnaire screening a large sample, followed by in-depth assessments of a sub-sample
selected according to the results of screening. Multiple informants were used in both phases.
All 9- to 11-year-old children attending state schools on the island were included in the primary
survey. A 4-year follow-up was carried out for children identifi ed with psychiatric problems when
they were approximately 14 years old.

Question 15

The point prevalence of any ICD-10 disorders in 5- to 15-year-old children is
estimated to be around
A. 1%
B. 5%
C. 10%
D. 20%
E. 25%

Answer 15

C. Numerous cross-sectional epidemiological surveys have confi rmed that psychopathology
in young people is common, with most studies estimating the prevalence to be between 10% and
20%. In a study that included more than 10 000 children, overall rates of psychiatric disorders
in 5- to 15-year-old children in UK was estimated to be around 9.5%. A review of 49 surveys
worldwide indicated an average point prevalence of 12.9% for psychiatric disorders in children.
Emotional disturbances and behavioural disorders are equally common. Only a small
proportion – between 10% and 30% – of children with a psychiatric disorder make contact
with specialist mental health services.

Question 16

Comparable male and female prevalence rates are found for which of the
following psychiatric disorders in children?
A. Eating disorders
B. Hyperactivity disorders
C. Nocturnal enuresis
D. Selective mutism
E. Tourette’s syndrome

Answer 16

D. Pervasive developmental disorders such as autism and Asperger’s syndrome are more
common in boys. Attention defi cit hyperactivity disorder, tic disorders, oppositional defi ance, and
conduct disorders are also seen more often in boys than in girls. The rate of depression seems
equal between both sexes before puberty. School refusal and selective mutism are also equally
common in both boys and girls. Depression after puberty, specifi c phobia, eating disorders, and
enuresis in daytime are more common in girls. Nocturnal enuresis in older children is more
prevalent in boys.

Question 17

According to the Isle of Wight study the ratio of boys to girls with conduct
disorder is
A. 4:1
B. 2:1
C. 1:2
D. 10:1
E. Conduct disorder was not diagnosed in girls

Answer 17

A. Conduct disorders are four times more common in boys than in girls according to the
Isle of Wight study. Girls are more prone to use verbal and relational violence, such as exclusion
from groups and character defamation, than the physical attacks seen in boys. Consequently,
girls are violent in a way that can be diffi cult to document and to describe as conduct disorder
symptoms; this may be a reason for under-diagnosis of conduct issues in girls.

Question 18

Reactive attachment disorder is a recognized category in both ICD-10 and
DSM-IV. Which of the following criteria used for diagnosing this condition is
mentioned in DSM-IV but not ICD-10?
A. Markedly disturbed inappropriate social relatedness
B. The disturbance does not meet the criteria for pervasive developmental disorder
C. Onset before 5 years of age
D. A history of signifi cant neglect
E. The disturbance in relationships is a direct result of abnormal care-giving

Answer 18

E. The core features of reactive attachment disorder (RAD) are preserved across
both diagnostic nosologies, ICD and DSM. But the focus on subtypes and emphasis on the
pathogenic nature of care giving are different. The DSM-IV includes inhibited and disinhibited
types of RAD. In ICD-10, the term reactive attachment disorder stands for inhibited type, while
disinhibited attachment disorder is separately defi ned. Both ICD and DSM endorse problems
of social relatedness in RAD. Age of onset criteria (before 5 years) and exclusion of pervasive
developmental disorders are common for both nosologies. In addition, DSM-IV also requires the
presence of a known history of grossly pathogenic care, suggesting a causal link. Children with the
disinhibited subtype may appear indiscriminately social.

Question 19

The term frozen watchfulness is used in description of which of the
following psychiatric conditions?
A. Inhibited reactive attachment disorder
B. Autism
C. Selective mutism
D. Social anxiety disorder
E. Post-traumatic stress disorder

Answer 19

A. The term ‘frozen watchfulness’ describes an alertness or even hypervigilance that is
maintained despite an overall inhibition of motor activity that may include mutism. Reactive
attachment disorder (RAD) is associated with markedly disturbed and developmentally
inappropriate social relatedness beginning before age 5 years. It commonly presents as persistent
failure to initiate or respond to most social interactions. The responses can be excessively
inhibited, hypervigilant, or highly ambivalent and contradictory. This is associated with avoidance
of resistance to comforting or exhibiting a frozen watchfulness. This type of RAD is called the
inhibited type. In disinhibited type, diffuse attachments manifested by indiscriminate sociability
with marked inability to exhibit appropriately selective attachments are seen. This frozen
watchfulness is different from aloofness seen in autism or dissociative features seen in PTSD.
Frozen watchfulness is also seen in young victims of physical abuse

Question 20

Which of the following best defi nes the diagnosis of specifi c reading
disorder when assessed using psychometric measures of reading age?
A. Reading age is below the 10th percentile of the peers
B. Reading age is one standard deviation below the expected
C. Reading age is two standard deviations below the expected
D. Reading age is three standard deviations below the expected
E. Reading age is below the 20th percentile of the peers

Answer 20

C. According to current classifi catory systems, a learning disorder such as specifi c reading
disorder can be diagnosed when the child achieves substantially lower than expected scores on
individually administered, standardized tests of components of learning (reading, mathematics, or
written expression) for a given age, schooling, and level of intelligence. Thus an explicit reference
to psychometric assessments is made when diagnosing learning disorders. But a specifi c guideline
as to the statistical meaning of being substantially below the expected norm is not clearly
delineated in DSM IV. Nevertheless, ICD-10 states a score that is at least 2 standard errors of
prediction below the expected value as diagnostic criteria for specifi c developmental disorders of
scholastic skills.

Question 21

A 10-year-old boy makes repeated errors in reading and spelling with
substitutions and omissions of letters. He is slow in reading with considerable
hesitations. All of the following features are expected in this child except
A. Minor neurological abnormalities
B. Socially disadvantaged home setting
C. Lower rates of conduct disorder
D. Higher rates of similar problems in the family
E. Higher rates of emotional problems

Answer 21

C. This child is most likely having specifi c reading disorder. This is associated with higher
prevalence of emotional disturbances and conduct disorder. It is more often seen in boys than
girls. Minor soft neurological signs are frequently seen in children with this disorder, suggesting a
neural developmental abnormality.

Question 22

The most consistent genetic locus implicated in specifi c reading disorder is
A. Chromosome 6p
B. Chromosome 9p
C. Chromosome 12p
D. Chromosome 4p
E. Chromosome 1p

Answer 22

A. Specifi c reading disorder is regarded to have signifi cant genetic aetiology, with multiple
genes contribute to the biological risk factor. The candidate regions are abbreviated as DYX1
to DYX9 on chromosomes 15q, 6p, 2p, 6q, 3cen, 18p, 11p, 1p, and Xq, respectively. Of these, the
most consistent fi ndings seem to be the role of chromosome 6.

Question 23

Which of the following is a common condition in childhood that is not listed
as a separate disorder in ICD-10?
A. Sleepwalking
B. Stuttering
C. Tic disorder
D. Autism
E. Sibling rivalry

Answer 23

B. Among the specifi c disorders of psychological development listed in the question,
stuttering is not a separate diagnostic category in the current ICD-10, Chapter V. Stuttering has a
high incidence between second and fourth years of life affecting 4% to 5% of the population with
nearly equal sex ratio at the start. Normal developmental dysfl uencies tend to occur in the larger
linguistic units such as words, phrases, and sentences. In stutterers this occurs in repetitions of
syllables and prolongation of sounds. Recovery usually occurs by adolescence and is more likely
in girls; nearly 1 in 30 children have stuttering though only 1% of adolescents show stuttering.
A familial component is noted in stuttering - the risk in fi rst-degree relatives being more than
three times the population risk.
Sleepwalking, sibling rivalry disorder, tic disorder and autism are defi nite diagnostic categories in
ICD-10.

Question 24

All of the following are recognized associations with specifi c reading
disorder except
A. Diffi culty in visual scanning
B. Right – left confusion
C. Age related spontaneous resolution
D. Higher rates in epileptic children
E. Deterioration in acquired language skills

Answer 24

E. Deterioration of already acquired language skills is not seen in specifi c reading disorder
or dyslexia. Neurodevelopmental basis for dyslexia is suggested by the similarity of certain
symptoms in dyslexic children and the neurological syndrome of `visual word blindness’ that
results from damage to the left inferior parieto-occipital region (more specifi cally, the left angular
gyrus). This region is speculated to have a role in processing the optic images of letters; damage
to this region may lead to defects in visual scanning. It is also noted that dyslexic children have
poor or delayed brain lateralization, especially for language. The high incidence of left-handers,
right-left confusion and the mirror-writing phenomenon noted in dyslexia can be considered as
indirect support to this notion. Epileptic children may have higher incidence of dyslexia. General
improvement with age suggests a brain maturational delay in the aetiology of dyslexia.

Question 25

The prevalence of autism is estimated to be around
A. 6 per 1000 children
B. 10 per 1000 children
C. 1 per 10000 children
D. 1 per 1000 children
E. 1 per 100000 children

Answer 25

D. Preliminary surveys regarding epidemiology of autism reported 2 -5 cases of autism
per 10 000 children. Wide variations have been reported in later studies ranging from 0·7 to
21 per 10 000 children (median 4–5 per 10 000). At present, at least one in 1000 children are
estimated to have autism. Differences in methodology of surveys and wide variations in the
defi nition of autism are the main reasons behind such variations. It is noted that boys have
three-to-four-fold higher rates of autism.

Question 26

Which of the following condition is associated with intractable epilepsy,
autism-like features and skin lesions in children?
A. Congenital hypothyroidism
B. Fragile X syndrome
C. Tuberous sclerosis
D. Foetal alcohol syndrome
E. Benzodiazepine use in pregnancy

Answer 26

C. Tuberous sclerosis is an autosomal dominant genetic multisystem disorder characterised
by widespread hamartomas in the brain, heart, skin, eyes, kidney, lung, and liver. Most features
of tuberous sclerosis become evident only in childhood after 3 years of age. The affected genes
TSC1 and TSC encode for proteins hamartin and tuberin respectively. Epilepsy is seen in
60–80% tuberous sclerosis cases and is thought to be secondary to changes of GABA receptors
in dysplastic neurons, and enhanced excitation via glutamate receptors in cortical hamartomas.
The epilepsy is generally of an early onset and is often intractable in severity. Hypomelanotic
macules are the most common dermatological manifestation; they are seen in 90–98% of patients
with tuberous sclerosis.

Question 27

During clinical assessment of temper tantrums in a child the most
important initial step is to
A. Assess IQ of the child
B. Elicit family history of temper tantrums
C. Explore parental limit setting behaviour
D. Explore suicidal ideas in the child
E. Record family history of criminality

Answer 27

C. Temper tantrums are common in children between the ages of 18 months and 4 years.
Tantrum behaviours range from simple crying to dramatic attention-seeking events such as
breath holding and head banging in otherwise normal children. Often parents may be reinforcing
tantrum behaviour without knowledge and may have an inconsistent approach to discipline and
limit setting. Hence the fi rst step in assessment of a family with a child throwing frequent temper
tantrums is discovering why parents are not able to set consistent limits.

Question 28

Controlled evaluations of family therapy in child psychiatric conditions have
demonstrated signifi cant benefi cial effects for which of the following?
A. Anorexia nervosa in adolescents
B. Pervasive developmental disorder
C. Hyperkinetic disorder
D. School refusal
E. Specifi c reading disorder

Answer 28

A. The strongest evidence base for using family therapy exists for anorexia nervosa in
adolescents. By the end of family therapy sessions more than 50% adolescent girls reach a healthy
weight; it is estimated that more than 60% achieve recovery on follow up. Encouraging parents to
take an active role is seen as a vital component; not involving the parents in the treatment leads
to the worst outcome and may delay recovery considerably. Other conditions with evidence base
for the use of systemic family therapy include childhood mood disorders, substance abuse and
conduct problems in children.

Question 29

Family therapy is indicated in all of the following situations in child
psychiatry except
A. The child’s symptoms are an expression of family’s malfunction
B. Individual therapy for the child is not effective
C. Family diffi culties are identifi ed during the course of another therapy
D. The marriage of the child’s parents is breaking up
E. Family spontaneously seeks the therapy

Answer 29

D. Family therapy considers the symptoms in a child to be expression of family dysfunction.
It can be used if such dysfunctions are evident during assessment, or if individual therapy fails
or to manage family diffi culties arising in the course of other treatments. As in other forms of
psychotherapy, no blanket indications and contraindications can be listed for family therapy.
But there are some instances in which therapists do not advise the family to undergo therapy.
In families where parental marital relationship is breaking down, highly fi xed psychopathology that
blocks any communication in family sessions and extreme schizoid or paranoid pathology are
some of the instances where family therapy does not come as fi rst choice of psychotherapy.

Question 30

Which of the following scales is used as a screening instrument to identify
possible developmental diffi culties that need further assessment?
A. British ability scales
B. Denver screening test
C. Neale analysis
D. Stanford Binet test
E. Weschler scale

Answer 30

B. Denver developmental screening test can be applied from birth to 6 ½ years to identify
delays in personal, language, motor and social development in children. It is purely a screening
tool and any children identifi ed to have developmental delays should undergo further assessment.
Neale analysis of reading is a specifi c test of educational attainment (reading accuracy and
comprehension). Stanford Binet test measures IQ using norms starting from age 2 to adulthood.
Wechsler intelligence scale for children tests IQ for children between ages 6 – 14 years.
A preschool and primary school version to test children aged 3 – 7 is also available. British ability
scales are tests of intelligence covering varied areas such as speed of processing, spatial imagery,
short term memory, perceptual matching and application of knowledge.

Question 31

The prevalence of bullying is estimated to be around
A. 1–2% of children, at least once a week
B. 2–8% children, at least once a month
C. 2–8% children, at least once a day
D. 12–18% children, at least once a week
E. 2–8% children, at least once a week

Answer 31

E. A large survey in United Kingdom reported that 10% of pupils at a secondary school had
been bullied during one term, with 2–8% (average 4%) reporting being bullied at least once a
week. The commonest type of bullying is general name calling, followed by being hit, threatened,
or having rumours spread about one. Bullying is more prevalent among boys; 30% of children do
not tell anyone that they are bullied. This percentage is higher for boys and older children

Question 32

Which of the following attachment pattern is the best predictor of future
development of conduct problems?
A. Disorganized
B. Secure
C. Ambivalent
D. Resistant
E. None of the above

Answer 32

A. Various aetiological contributors for conduct disorders include family stressors, parental
discipline, child characteristics such as temperament or neurobiological problems and attachment
relationships. Attachment behaviours include those infant behaviours that are activated by stress
and that have as a goal the reduction of arousal and reinstatement of a sense of security. Such
reinstatement is usually best achieved in infancy by close physical contact with a familiar caregiver.
In addition to Ainsworth’s initial description of secure, ambivalent and avoidant attachment
patterns, Main and Solomon described a fourth infant attachment category called disorganized
type. As many as 10 - 15% of children in some samples show disorganized type of attachment.
Such disorganized attachment pattern presents with high levels of aggression, more externalizing
and controlling behaviour in middle childhood. This is strongly related to aggressive disorders
such as conduct disorder in childhood.

Question 33

Ainsworth’s strange situation procedure is usually used to study patterns of
attachment in which of the following the age groups?
A. 30–36 months
B. 12–18 months
C. 3–6 months
D. 24–36 months
E. 18–30 months

Answer 33

B. Strange Situations procedure was initially employed by Mary Ainsworth to study
attachment behaviours in children between ages 12 to 18 months. The experiment takes place
in a room with a one-way mirror and attractive toys. The expected behaviour includes running
around, clinging and reunion; so the children need to be somewhat mobile between ages 12 and
18 months.

Question 34

Blood levels of which of the following substances has been adversely
associated with IQ of a child?
A. Iron
B. Lead
C. Lithium
D. Magnesium
E. Sodium

Answer 34

B. Lead is established to have neurotoxic effects on growing brain; blood lead
concentrations above 10 μg per decilitre (0.483 μmol per litre) are associated with adverse
intellectual functioning and social–behavioural conduct. A blood lead concentration of 10 μg
per decilitre or higher is designated as a ‘level of concern’ by the World Health Organization.
It is estimated that a loss of 7.4 IQ points takes place with a lifetime average blood lead
concentration of up to 10 μg per decilitre.

Question 35

The multiaxial system of classifi cation for child and adolescent psychiatric
disorders in ICD-10 consists of
A. three axes
B. four axes
C. fi ve axes
D. six axes
E. seven axes

Answer 35

D. Multiaxial classifi cation is very useful for child and adolescent psychiatric disorders due
to the inherent complexity of information required in diagnosis and treatment. In the absence
of a multiaxial system, certain conditions may easily get overlooked, such as the developmental
learning disorders in a child with conduct problems. But the placement of certain disorders
within a multiaxial framework may be problematic especially when the disorders have no specifi c
aetiology and spans across multiple axes used in the classifi cation. ICD-10 recommends six axes
for diagnosing mental health problems in children. These include (1) psychiatric syndromes;
(2) disorders of psychological development; (3) intellectual level; (4) medical conditions;
(5) abnormal psychosocial situations; (6) global assessment of functioning. In contrast DSM-IV has
fi ve axes in total, as psychiatric symptoms and developmental disorders come under axis 1.

Question 36

The average age range of attaining physical changes of puberty in boys is
A. 10–12 years
B. 11–13 years
C. 13–16 years
D. 16–19 years
E. 9–10 years

Answer 36

C. The average age at which physical changes of puberty occur is different for boys and
girls. Tanner staging is often used to assess physical changes in puberty and stage 2 genital
changes are used to defi ne onset of puberty. It varies between 11 and 13 in girls, and 13 and
17 in boys. It must be noted that the criteria that more accurately refl ect gonadal activity are
breast development in girls and genital growth in boys. As these are diffi cult to ascertain, reliable
measurement is not possible using observations of physical maturity; puberty as assessed by
hormonal measurements of the hypothalamic pituitary gonadal axis is well established before
physical signs appear.

Question 37

The proportion of children with childhood autism that show improvement
by the age of 6 years is
A. 1–2%
B. 5–8%
C. 8–10%
D. 25–30%
E. 10–20%

Answer 37

E. By the age of 6 years, 10–20% of individuals with autism begin to improve. Eventually
15% of individuals achieve satisfactory self-suffi ciency while another 20% manage with
minimal periodic support. The remainder of at least 60%individuals does not achieve suffi cient
self suffi ciency for an independent life. This outcome is variable according to degree of
communicative language developed and IQ.

Question 38

In families with one autistic child, the risk of a further autistic child is about
A. 1–1.5%
B. 3–5%
C. 10–15%
D. 30–35%
E. 50–60%

Answer 38

B. In families with one autistic child the risk of a further autistic child is around 3 – 5%.
This sibling risk rate for autism denotes a tenfold increase over general population rates.
Epidemiological studies of same sex autistic twins have identifi ed around 60% monozygotic
concordance while 0% for dizygotic twins. This difference becomes further pronounced when a
broader autistic phenotype of related cognitive or social abnormalities are considered (92% of
MZ pairs vs. 10% of DZ pairs). The risk to a monozygotic co-twin is estimated to be over
200 times the general population rate.

Question 39

The estimated heritability of attention defi cit hyperactivity disorder
(ADHD) is around
A. 10%
B. 25%
C. 33%
D. 50%
E. 70%

Answer 39

E. The heritability of ADHD is estimated to be around 70%. Twin studies performed in
several countries have shown that the average genetic contribution is 70–80% while non genetic
variance contributes to 20–30%. It is also observed that 6% of adoptive parents of ADHD
probands have ADHD compared to 18% of the biological parents of ADHD probands and 3%
of the biological parents of the control probands. Siblings of children with hyperkinetic disorder
have a 2–3 times greater risk of the disorder than siblings of normal controls

Question 40

All of the following factors predict poor outcome in conduct disorders
except
A. Late-onset conduct problems
B. Multiple and varied symptoms and behaviours
C. Parental psychiatric disorder
D. Parental criminality
E. Associated hyperactivity

Answer 40

. A. Childhood conduct disorder can continue as adult antisocial personality disorder. A wide
range of other psychiatric disorders including substance abuse, major depression, psychosis and
various adverse outcomes such as suicide, delinquency, educational diffi culties and unemployment
have been associated with conduct disorder. Evidence on prognosis of conduct disorder
suggests dose-response relationship: The higher the number and variety of disruptive behaviours,
the worse the adult outcomes. But most adolescents with conduct disorder do not develop
antisocial personality in adulthood. Those who do not develop adverse outcomes as adults are
most likely to have a late onset, adolescent-limited disorder rather than a life-course persistent
problem with early onset. Other poor prognostic factors include severity, comorbid hyperactivity,
pervasive behavioural disruption across varied settings and continuous exposure to risk factors.

Question 41

Among the juvenile delinquent population, the most commonly committed
offence is
A. Sexual assault
B. Homicide
C. Fraud
D. Property offences
E. Offences related to terrorism

Answer 41

D. Among juvenile delinquents, the most common offences are against property. Boys
are more delinquent than girls in a ratio of 4 to 11 delinquent boys for every delinquent girl.
Among boys who get convicted only half get reconvicted. But most (nearly 75%) with repeated
convictions become adult offenders.

Question 42

All of the following are associated with higher rates of nocturnal enuresis
except
A. Family history of enuresis
B. Male sex
C. Overcrowded home
D. Rigid parental toilet training
E. Stressful life events

Answer 42

D. Most enuretic children are free from psychiatric disorders. But the rate of psychiatric
disorders is higher in enuretic than non-enuretic children. Children growing up in large families
in overcrowded conditions have higher rate of enuresis. Stressful life events may form a starting
point of secondary enuresis in children. Toilet training methods used by parents have not shown
to be associated with enuresis. Enuresis tends to run in families; a positive family history can be
related to positive treatment outcome. Many chromosomal loci have been identifi ed - 13q, 12q, 8,
and 22. Rarely some families show an autosomal dominant mode of transmission with penetrance
above 90%.

Question 43

The most common form of medically unexplained symptom complained by
children is
A. Recurrent chest pain
B. Recurrent headaches
C. Recurrent fever
D. Recurrent memory loss
E. Recurrent palpitations

Answer 43

B. Recurrent headaches are the most common somatic symptom with no medical
explanation complained by children, followed by abdominal pain. 10 to 30% of children admit
having frequent headaches (at least weekly) while 7 to 25% admit having abdominal pain. Chest
pain is reported by approximately 10% of school aged children. At least 7.5% of children admit to
other musculoskeletal pains. Chronic fatigue syndrome appears to be uncommon in children with
estimated prevalence less than 1%.

Question 44

A psychometric test involves experimental creation of a situation in which
a test person has to distinguish his or her own knowledge of a hidden object
from the knowledge of the others. This test is called
A. Sally & Anne Task
B. Draw a Person Test
C. Thematic Apperception Test
D. Lucy & Linda Task
E. Rorschach’s test

Answer 44

A. The Sally and Anne Task involves metarepresentation of another person’s mental state.
Two test characters Sally and Anne are shown in a picture. Sally leaves a toy at a place. Anne
hides the toy at a different place in the absence of Sally. When Sally returns, where will she look
for the toy - the place it was before she left the scene or the place where it had been moved by
Anne? This requires a subject to distinguish his or her own knowledge that an object has been
hidden by Anne in the absence of Sally from the knowledge of Sally. The test subject must be
able to refl ect Sally’s mental state i.e. ‘I know that she does not know where the object really is’.
The Sally and Anne Test therefore tests understanding a fi rst order false belief. As theory of mind
does not develop fully before age 4, children under this age very often fail the test

Question 45

Which is the most consistently identifi ed abnormality in neurobiological
studies of autism?
A. Elevated urinary dopamine metabolites
B. Elevated urinary metanephrines
C. Raised cerebrospinal fl uid (CSF) 5-HIAA
D. Raised serotonin blood levels
E. Low platelet MAO levels

Answer 45

D. One of the most consistently observed biological fi ndings in autism is increased
serotonin levels in the blood, which is noted in 30–50% of children with autism. The high whole
blood serotonin is also noted among family members of autistic patients. Essentially this whole
blood level refl ects platelet serotonin

Question 46

Comparing autism and Asperger’s syndrome, which of the following is true?
A. Head growth deceleration is seen in autism but not Asperger’s syndrome
B. High male: female ratio is seen in Asperger’s syndrome but not autism
C. Seizures are more common in Asperger’s syndrome than autism
D. Social skills before the age of 3 is normal in Asperger’s syndrome
E. The degree of learning disability is milder in Asperger’s syndrome

Answer 46

E. In both autism and Asperger’s syndrome, males outnumber females. Communications
skills are generally poor in autism, but fairly developed in Asperger’s patients. Circumscribed
narrow interests are usually severe in Asperger’s syndrome. Seizures are uncommon in Asperger’s
patients while it is commoner in autism. Social skills are poorly developed in both autism
and Asperger’s disorder. IQ ranges from mild learning disability to normal level in Asperger’s
syndrome, while most patients with autism have low IQ. Head growth deceleration is not seen in
both autism and Asperger’s syndrome; it is a feature of Rett’s disorder

Question 47

All of the following symptoms are more common in depression associated
with learning disability than in those of normal intelligence except
A. Irritability
B. Sleep disturbances
C. Tearfulness
D. Decline in social skills
E. Hypochondriasis

Answer 47

E. Though most symptoms of depression seen in learning disabled individuals are same as
those seen in general population, certain differences exist. Cognitive syndrome of depression
including memory disturbance and loss of concentration are often not detected. Similarly, guilt
and recurrent thoughts of suicide are under-reported. But biological changes associated with
depression such as psychomotor retardation, disturbed sleep, appetite and weight loss and
diurnal variation in symptoms are more readily detected. Some symptoms may be more marked
in depressed individuals with severe learning disability e.g. psychomotor agitation, irritability and
behavioural disturbance. Decline in established activities of daily living and tearfulness may be
signs of hidden depression in some patients. Hypochondriasis and other formed beliefs are
rarely seen.
Prasher V. Presentation

Question 48

A residential care home has 12 residents with learning disability. The nurses
at the care home want to use a screening instrument at regular intervals
to detect likely mental health problems among the residents. Which of the
following would be most suitable?
A. Psychiatric Assessment Schedule for Adults with Developmental Disabilities
B. Diagnostic interview schedule
C. Camberwell Assessment of Need for Adults with Developmental and Intellectual
Disabilities
D. Schedule for Clinical Assessment in Neuropsychiatry
E. General Health Questionnaire

Answer 48

A. Measurement of psychopathology in people with learning disabilities is diffi cult.
This issue is partly addressed by the Psychiatric Assessment Schedule for Adults with
Developmental Disabilities (PAS–ADD) interview. A shorter version is also available and can be
used as a screening tool by untrained people to identify clients with learning disabilities at risk
of developing a psychiatric disorder. It contains 29 items concerning symptoms of psychiatric
disorders, split into fi ve scales that combine to produce three total scores: 1, affective/neurotic
disorder; 2, possible organic disorder; and 3, psychotic disorder. Scores equal to or above
specifi ed thresholds indicate if a further assessment is necessary

Question 49

An 8-year-old boy suffers from episodes of sudden but brief fl exion of neck
and trunk and fl exion of legs at the hips since the age of one. He has severe
mental retardation. Which of the following EEG pattern is most likely in
this boy?
A. Diffuse triphasic delta waves
B. Flat EEG trace
C. Background high voltage slow waves intermixed with asynchronous spikes in both
hemispheres
D. Low voltage EEG with no spikes
E. Periodic 3/second spikes

Answer 49

C. This child is most likely to have infantile spasms. This condition appears usually at the
ages of 4 to 6 months. The spasms are a form of epilepsy and are characterised by sudden, brief
fl exion of neck and trunk, raising both arms forwards or and fl exion of legs at the hips. A cry
may be associated with the attack. The EEG is generally chaotic with slow waves of high voltage
intermixed with asynchronous spikes in both hemispheres. This pattern of EEG fi ndings is called
hypsarrhythmia. Patients with infantile spasms limited to one side may have a surgically removable
cortical dysplasia. Infantile spasms are also noted in infants with Down syndrome or tuberous
sclerosis. The term West syndrome is applied to the triad of infantile spasms, hypsarrhythmia, and
mental retardation.

Question 50

Which of the following is true with respect to the use of medications to
treat behavioural problems in learning disabled individuals?
A. Antidepressants are the most effective intervention
B. Haloperidol is the most effective intervention
C. Low dose lorazepam has the best evidence base
D. Placebo effect surpasses active medications
E. Risperidone is more effective in high doses

Answer 50

D. Despite widespread use of antipsychotics to treat challenging behaviour in learning
disabled adults, the evidence is scarce. ‘Neuroleptics for Aggressive Challenging Behaviour in
Intellectual Disability’ (NACHBID) was a multicentre study that compared first-generation and
second-generation antipsychotic drugs with placebo in patients with aggressive challenging
behaviour. A reduction in aggression was noted with both antipsychotic treatments and placebo
use after 4 weeks; the greatest response was with placebo. No differences between groups were
observed in terms of aberrant behaviour, quality of life, general improvement or effect on carers.
The combination of placebo effect, the psychological effect of a formal external intervention and/
or spontaneous resolution surpasses than the effect of medications.