Child Psychiatry: Assessment, Examination, and Psychological Testing Medicine Flashcards
At what age does a normally developing child reach half of his or her potential adult height? 1 year old 2 years old 3 years old 4 years old 5 years old
The answer is B
By the time a normally developing child reaches the age of 2 years, his or her
has reached half of his or her adult height potential. Especially important,
however, is the astounding maturation that occurs in the central nervous system
(CNS). This development allows children to acquire several paramount skills,
including the development of motor abilities, the maturation of perceptual
abilities and pathways, and the acquisition of language
Which of the following tools is considered most appropriate to facilitate
the play component of an interview?
A. Chess
B. Puppets
C. Video games
D. Elaborate toys
E. Stock characters (e.g., Barbie or Disney figures)
The answer is B
Children younger than 7 years of age have limited capacities to verbally recount
their feelings or interpersonal interactions. For these younger children as well
as a number of older ones, play is a useful adjunct to direct questioning and
discussion and is often a less challenging mode for children. Some children find
it easier to communicate in displacement; thus, imaginative play with puppets small figures, or dolls can provide the interviewer with useful inferential
material about the child’s concerns, perceptions, and characteristic modes of
regulating affects and impulses.
The skilled interviewer will facilitate the child’s engagement in play without
prematurely introducing speculations or reactions that might distort or cut
short the presentation of certain types of material. During the course of play,
the clinician follows the sequences of play content, noting themes that emerge,
points at which a child backs away from a story or shifts to a new activity, and
situations in which the child gets "stuck" or falls into a repetitive loop. To
facilitate the play components of an interview, the interview room should have a
supply of human and animal figures or dolls and appropriate props. These should
be relatively simple because elaborate toys can serve as distractions rather
than as vehicles for expression. Stock characters (e.g., Barbie or Disney
figures) may impose their own specific story lines and thus limit access to the
child’s own concerns.
The content of the child’s play provides important details of the mental status
examination. During imaginative play, the clinician observes the child’s
coordination and motor skills, speech and language development, attention,
ability to relate, capacity for complex thought, and affective state. Absence of
imaginative play or limited, concrete, non-interactive play may indicate a
pervasive developmental disorder.
More complex games such as chess should be avoided given their demand for
concentration, which precludes conversation. Video games likewise tend to serve
as an impediment to meaningful interaction.
Which statement is true of a person who has acquired a second language
during childhood?
A. There is only one language center in the cortical region.
B. Both language centers appear in the cortical region.
C. There are no language centers in the cortical region.
D. Language centers do not appear in the cortical region.
E. Second language centers only appear in an adult’s cortical region.
The answer is B
In children with a first and second language, the language centers appear in the
same cortical region, but when a second language is acquired in adult life, the
new language center is not represented in the same cortical region as the first
language
Structured assessment instruments for infants and young children
A. yield diagnoses
B. show only fair reliability and validity
C. are highly reliable in predicting later performance on IQ assessment
D. include the Denver Developmental Screening Test (Denver II) and the Bayley
Scales
E. all of the above
The answer is D
A variety of instruments exist for the structured assessment of infants and
young children, and each has somewhat different goals, theoretical orientation,
and psychometric properties. These instruments do not yield diagnoses but rather
detail the child’s developmental progress in various areas relative to a
normative population. For example, the Denver Developmental Screening Test
(Denver II) is suitable for screening use by pediatricians and trained
paraprofessionals to help identify children with significant motor, social, or
language delays requiring more complete evaluation. Population-specific norms are also available for assessing children from families of various ethnic or
educational backgrounds. The Bayley Scales of Infant Development II, which are
administered by a trained assessor, can be used to evaluate children 1 to 42
months of age and include a mental scale (assessing information processing,
habituation, memory, language, social skills, and cognitive strategies), a motor
scale (assessing gross and fine motor skills), and a Behavior Rating Scale for
assessing qualitative aspects of the child’s behavior during the assessment.
This well-standardized instrument yields standard scores for a Mental Development
Index and Psychomotor Development index.
Although these kinds of tests show good (not fair) reliability and validity,
their ability to predict later performance on IQ assessment or later adaptive
functioning is highly variable. Among the reasons for this weakness of
prediction are the intervening effects of social and family environment and the
heavy emphasis infant tests place on perceptual and motor skills that may have
relatively little to do with information-processing abilities
Of the following diagnostic laboratory tests used in evaluation of children presenting with psychiatric problems, the one most likely to impact ultimate diagnosis is: A. computed tomography (CT) B. thyroid function test C. magnetic resonance imaging (MRI) D. positron emission tomography (PET) E. chromosomal analysis
The answer is E
The clinical utility and cost effectiveness of routine laboratory and imaging
studies of children presenting with psychiatric symptoms has not been thoroughly
studied. Most guidelines for performing these tests for children derive from
data from adult studies. Adult studies generally suggest that routine laboratory
tests such as thyroid function tests are not clinically useful in settings such
as outpatient psychiatry clinics or most inpatient units. Diagnostic tests are
of greater utility in certain psychiatric settings where patients are at higher
risk for medical illness, such as emergency departments, substance abuse
treatment settings, AIDS clinics, and geriatric clinics.
Additionally, these tests are considered to be worthwhile in patients with
first-onset psychosis, depression, mania, or dementia. Furthermore, routine
laboratory screening is more likely to yield clinically useful information when
signs or symptoms of physical illness are present.
More specialized diagnostic evaluations (CT, MRI, electroencephalography) also
appear to provide low yield of clinically useful information. In a study of 200
consecutive child psychiatric inpatients, these evaluations were done only when
"clinically indicated." However, despite their judicious use, the tests
provided clinically relevant information in only seven of 200 patients (3.5
percent). In the same sample population, chromosomal analysis proved to be the
most informative test, yielding new medical diagnoses in five of 32 children on
whom these analyses were performed (15.6 percent). More specialized neuroimaging
techniques, such as PET, single photon emission computed tomography (SPECT), and
functional magnetic resonance imaging (fMRI), currently have no routine clinical
or diagnostic utility in child and adolescent psychiatric populations.
MSE in infant and toddler
Appearance
Size, level of nourishment, dress and hygiene, apparent maturity compared with
age, dysmorphic features (e.g., facies, eye and ear shape and placement,
epicanthal folds, digits), abnormal head size, cutaneous lesions)
Apparent reaction to situation
Note where evaluation takes place and with whom.
Initial reaction to setting and to strangers: explores; freezes; cries; hides
face; acts curious, excited, apathetic, or anxious (describe)
Adaptation
Exploration: when and how child begins exploring faces, toys, strangers
Reaction to transitions: from unstructured to structured activity; when examiner
begins to play with infant; cleaning up; leaving
Self-regulation
State regulation: an infant’s state of consciousness ranges from deep sleep
through alert stages to intense crying. Predominant state and range of states
observed during session; patterns of transition (e.g., smooth vs. abrupt
capacity for being soothed and self-soothing; capacity for quiet alert state).
Some of these categories also apply to toddlers.
Sensory regulation: reaction to sounds, sights, smells, light and firm touch;
hyperresponsiveness or hyporesponsiveness (if observed) and type of response,
including apathy, withdrawal, avoidance, fearfulness, excitability, aggression
or marked behavioral change; excessive seeking of particular sensory input
Unusual behaviors; mouthing after 1 year of age; head banging; smelling objects;
spinning; twirling; hand flapping; finger flicking; rocking; toe walking;
staring at lights or spinning objects; repetitive, perseverative, or bizarre
verbalizations or behaviors with objects or people; hair pulling; ruminating; or
breath-holding
Activity level: overall level and variability (note that toddlers are often
incorrectly called hyperactive); describe behavior, e.g., squirming constantly
in parent’s arms; sitting quietly on floor or in infant seat; constantly on the
go; climbing on desk and cabinets; exploring the room; pausing to play with each
of six to eight toys
Attention span: capacity to maintain attentiveness to an activity or interaction;
longest and average length of sustained attention to a given toy or activity;
distractibility. Infants: visual fixing and following at 1 month; tracking at 2
to 3 months; attention to own hands or feet and faces; duration of exploration
of object with hands or mouth
Frustration tolerance: ability to persist in a difficult task despite failure;
capacity to delay reaction if easily frustrated (e.g., aggression, crying,
tantrums, withdrawal, avoidance)
Aggression: modes of expression; degree of control of or preoccupation with
aggression; appropriate assertiveness
Motor
Muscle tone and strength; mobility in different positions; unusual motor pattern
(e.g., tics, seizure activity), intactness of cranial nerves (e.g., movement of
face, mouth, tongue, and eyes, including feeding, swallowing, and gaze [note
excessive drooling])
Gross motor coordination. Infants: pushing up; head control; rolling; sitting;
standing. Toddlers: walking; running; jumping; climbing; hopping; kicking;
throwing and catching a ball. (It is useful to have something for the child to
climb on, such as a chair.)
Fine motor coordination. Infants: grasping and releasing; transferring from hand
to hand; using pincer grasp; banging; throwing. Toddlers: using pincer grasp;
stacking; scribbling; cutting. Both fine motor and visual-motor coordination can
be screened by observing how the child handles puzzles, shape boxes, a ball and
hammer toy, small cars, and toys with connecting parts.
Speech and language
Vocalization and speech production: quality, rate, rhythm, intonation,
articulation, volume
Receptive language: comprehension of others’ speech as seen in verbal or
behavioral response (e.g., follows commands); points in response to "where
is?" questions; understands prepositions and pronouns (include estimate of
hearing, especially in a child with language delay, e.g., response to loud
sounds and voice; ability to localize sound).
Expressive language: level of complexity (e.g., vocalization, jargon, number of
single words, short phrases, full sentences); overgeneralization (e.g., uses
"kitty" to refer to all animals); pronoun use, including reversal; echolalia,
either immediate or delayed; unusual or bizarre verbalizations. Preverbal
children: communicative intent (e.g., vocalizations, babbling, imitation,
gestures, such as head shaking and pointing); caregiver’s ability to understand
infant’s communication; child’s effectiveness in communication
Thought
The usual categories for thought disorder almost never apply to young children.
Primary process thinking, as evidenced in verbalizations or play, is expected in
this age group. The line between fantasy and reality is often blurred. Bizarre
ideation; perseveration; apparent loose associations; and the persistence of
pronoun reversals, jargon, and echolalia in an older toddler or preschooler may
be noted in a variety of psychiatric disorders, including pervasive developmental
disorders.
Specific fears: feared object; worry about being lost or separated from parent
Dreams and nightmares: content is sometimes obtainable in children 2 to 3 years
of age; Children do not always perceive it as a dream (e.g., "A monster came in
the front door")
Dissociative state: sudden episodes of withdrawal and inattention; eyes glazed;
"tuned out"; failure to track ongoing social interaction. Dissociative state
may be difficult to differentiate from an absence seizure, depression, autism,
or deafness. The context may be helpful (e.g., child with a history of neglect
freezes in a dissociative state as mother leaves room). Neurological or
audiological evaluation may be warranted.
Hallucinations: extremely rare except in the context of a toxic or medical
disorder; then usually visual or tactile
Affect and mood
The assessment of mood and affect may be more difficult in young children
because of limited language; lack of vocabulary for emotions; and use of
withdrawal in response to a variety of emotions from shyness and boredom to
anxiety and depression.
Modes of expression: facial; verbal; body tone and positioning
Range of expressed emotions: affect, especially in parent-child relationship
Responsiveness: to situation, content of discussion, play, and interpersonal
engagement
Duration of emotional state: need history or multiple observations
Intensity of expressed emotions: affect, especially in parent-child relationship
Play
Play is a primary mode of information gathering for all sections of the Infant
and Toddler Mental Status Exam. In very young children, play is especially
useful in the evaluation of the child’s cognitive and symbolic functioning,
relatedness, and expression of affect. Themes of play are helpful in assessing
older toddlers. The management and expression of aggression are assessed in play
as in other areas of behavior. Play may be with toys or with
Structure of child’s own or
another’s body (e.g., peek-a-boo, roughhousing), verbal (e.g., sound imitation
games between mother and infant), interactional, or solitary. It is important to
note how the child’s play varies with different familiar caregivers and with
parents versus the examiner. Structure of play
Content of play
Cognition
Relatedness of child to parents and to examiner
Attachment behaviours
Structure of play
Sensorimotor play
0 to 12 months: mouthing, banging, dropping, and throwing toys or other objects
6 to 12 months: exploring characteristics of objects (e.g., moving parts,
poking, pulling)
Functional play
12 to 18 months: child’s use of objects shows understanding and exploration of
their use or function (e.g., pushes car, touches comb to hair, puts telephone to
ear)
Early symbolic play
18 months and older: child pretends with increasing complexity; pretends with
own body to eat or sleep; pretends with objects or other people (e.g., "feeds"
mother); child uses one object to represent another (e.g., a block becomes a
car); child pretends a sequence of activities (e.g., cooking and eating)
Complex symbolic play
30 months and older: child plans and acts out dramatic play sequences, uses
imaginary objects; later, child incorporates others into play with assigned
roles
Imitation, turn taking, and problem solving as part of play
Types of attachment behaviours
Attachment behaviors: observe for showing affection, comfort seeking, asking for
and accepting help, cooperating, exploring, controlling behavior, and reunion responses. Describe age-related disturbances in these normative behaviors.
Disturbances often are seen in abused and neglected children (e.g., fearfulness,
clinginess, overcompliance, hypervigilance, impulsive overactivity, and
defiance; restricted or hyperactive and distractible exploratory behavior; and
restricted or indiscriminate affection and comfort seeking).
Techniques that are helpful in eliciting information and feelings from a
school-aged child include all of the following except
A. asking multiple-choice questions
B. asking the child to draw a family
C. using Donald Winnicott’s "squiggle game"
D. using only open-ended questions
E. using indirect commentary
The answer is D
Open-ended questions can overwhelm school-aged children and result in withdrawal
or shrugging of the shoulders; multiple-choice questions may elicit more
information from children in this age group. If a child is not adept with verbal
skills, asking the child to draw a family is often a way to break the ice and to
gain information about the child’s emotional experience. Activities such as
Winnicott’s "squiggle game," in which the examiner draws a curved line and
then takes turns with the child in continuing the drawing, may also open
communication with the child. Using indirect commentary, such as, "I once knew
a boy about your age who felt very sad when he moved away from all his
friends," helps elicit feelings from the child, although the clinician must be
wary of leading children into confirming what they believe the clinician wants
to hear.
Which of the following statements about personality tests for children is
true?
A. Personality tests and tests of ability have equal reliability and validity.
B. Both the Children Apperception Test (CAT) and the Thematic Apperception Test
(TAT) use pictures of people in situations.
C. The Rorschach test has not been developed for children or adolescents.
D. The Mooney Problem Checklist is a self-report inventory.
E. None of the above
The answer is D
The Mooney Problem Checklist is a checklist of personal problems and is a
self-report inventory, a series of questions concerning emotional problems,
worries, interests, motives, values, and interpersonal traits. The primary
utility of personality inventories is in the screening and identification of
children in need of further evaluation. Personality tests have lower reliability
and validity than tests of ability.
The Children Apperception Test (CAT) is different from the Thematic Apperception
Test (TAT) in that the CAT uses cards depicting animals and the TAT uses images
of people. The Rorschach test, one of the most widely used projective techniques,
has been developed in versions for children between the ages of 2 and 10 years
and for adolescents between the ages of 10 and 17 years
Figure 36.1 is part of a series of drawings used to test children for A. response to frustration B. psychosis C. depression D. impulsivity E. anxiety
The answer is A
Figure 36.1 is part of the Rosenzweig Picture-Frustration Study, in which a
series of cartoons is presented in which one character frustrates another. In
the blank space provided, the child writes the reply of the frustrated
character. From that reply, the clinician assesses the child’s response to
frustration; the response can range from passivity to violence. The test is not
used to measure psychosis, depression, impulsivity, or anxiety
Neurological soft signs include all of the following except A. contralateral overflow movements B. learning disabilities C. asymmetry of gait D. nystagmus E. poor balance
The answer is B
The term "neurological soft signs" was first used by Lauretta Bender in
reference to nondiagnostic abnormalities that are seen in some children with
schizophrenia. It is now evident that these signs do not indicate a specific
neurological or psychiatric disorder but are relatively common in children with
a wide variety of developmental disabilities. Learning disabilities are not
neurological soft signs, although children with low intellectual function or
learning disabilities often demonstrate these signs. Soft signs refer to both
behavioral findings, such as severe impulsivity or mood instability, and
physical findings, such as persistence of infantile reflexes, mild incoordination,
poor balance, contralateral overflow movements, asymmetry of gait, nystagmus,
and mild choreiform movements.
Neurological soft signs
Soft signs refer to both
behavioral findings, such as severe impulsivity or mood instability, and
physical findings, such as persistence of infantile reflexes, mild incoordination,
poor balance, contralateral overflow movements, asymmetry of gait, nystagmus,
and mild choreiform movements.
Physical anomalies with associated mental retardation include all of the following except A. multiple hair whorls B. low-set ears C. high-arched palate D. flattened philtrum E. persistent Babinski reflex
The answer is E
Physical anomalies or dysmorphic features are most frequently seen in children
with in utero exposure to toxic substances, chromosomal abnormalities,
developmental disabilities, speech and language disorders, learning disorders,
and severe hyperactivity. As with neurological soft signs, they are rarely
specific in determining a psychiatric or neurological diagnosis, but they are
important to document in the evaluation of a child and may prompt further
genetic, neurological, and psychiatric investigation. Physical anomalies include
multiple hair whorls, low-set ears, a high-arched palate, a flattened philtrum,
epicanthal folds, hypertelorism, transverse palmar creases, and increased head
circumference. The persistence of the Babinski reflex is a neurological sign
rather than a physical anomaly.
A 2-year-old boy presents with his father because of the family’s concern
that he is not developing appropriately. The child is poorly related to others,
often unable to engage using eye contact, and does not play with other children
during play dates. He has trouble expressing himself and continuously bangs his
chin against a chair. What is the most likely diagnosis?
A. Fetal alcohol syndrome
B. Tourette’s disorder
C. Schizotypal personality disorder
D. Autism
E. None of the above
The answer is D
Features of autism include impaired speech and nonverbal communication. These
patients’ ability to interact with others is impaired. They frequently present
with repetitive behaviors and poor eye contact. Autism is a diagnosis that is
typically made before the age of 3 years. Although mental retardation results
from fetal alcohol syndrome, one would also observe epicanthal folds, midfacial
hypoplasia, palpebral fissures, and other dysmorphic facial anomalies. Features of Tourette’s disorder include both motor and verbal tics. Patients with odd,
magical thinking who tend to be socially withdrawn may have schizotypal
personality disorder
