Development

Question 1

15 month old is seen in your office. What would make you the most concerned?

a) Not pointing to show interest
b) No words and part of a bilingual family
c) Cannot scribble with crayon

40. Which would be most concerning in a 15mo boy?
    a. Not pointing
    b. No words yet

Answer 1

No words yet
Expect first word by ~12mo

• Points to wants/desired objects (proto-imperative) by 12mo
• Points to show interest (proto-declarative) by 18mo
• Scribble: imitation ~12mo, spontaneously ~15mo

Question 2

5.Child with in-toeing and difficulty walking. What would make you suspicious that this is spastic diplegic CP?
a) Prematurity, global developmental delay, normal reflexes
b) Prematurity, delayed motor milestones, increased reflexes
c) Birth asphyxia, global developmental delay, normal reflexes
d) Birth asphyxia, delayed motor milestones, increased reflexes
————————-
10. An 18 month old boy presents with bilateral toe walking. Which findings on history and physical exam would support a diagnosis of spastic diplegic cerebral palsy?
A. Preterm delivery, delayed gross motor development, increased lower limb reflexes
B. Term delivery with asphyxia, delayed gross motor development, increased lower limb reflexes
C. Preterm delivery, global developmental delay, decreased lower limb reflexes
D. Term delivery with asphyxia, global developmental delay, decreased lower limb reflexes

Answer 2

Prematurity, delayed motor milestones, increased reflexes

Spastic diplegia

• most common
• prem, ischemia, infection, endo/metabolic
• PVLs!
• bilat spasticity
• increased DTR, pos clonus, pos Babinski
• Unlikely sz or ID

Question 3

7. The Mother of a 3.5 yo girl is concerned about her speech. She said her first words at 11 months and is speaking in 3 word sentences. There are no concerns with her development. She has begun to have difficulty with speaking. She will repeat the same word (mommy, mommy, mommy) and repeat sounds at the start of words (m-m-m-mommy), pause during speak and insert “uh” in the middle of a sentences. She has associated facial twitches and blinking. What do you recommend?
   a) Audiology
   b) Developmental assessment
   c) Reassure
   d) Refer to SLP

Developmental dysfluency vs stuttering

Answer 3

SLP b/c grimacing is unusual

Developmental Dysfluency
- occasional (once Q10 sentences)
- brief (<0.5s)
- repetition of sounds, syllables or words (start of word, no prolongations)
- worse when tired, excited, complex language, questions, anxious
- no tensions in facial muscles, no frustration
- better with singing, reading aloud, talking to pets/toys
Tx: reassure, SLP if more frequent dysfluencies or anxiety/discomfort

Child Onset Fluency Disorder (Stuttering)- DSM5
A. Disturb normal fluency. Inappropriate for age + language skills. Persist over time. >=1 of:
1. Sound + syllable repetitions
2. Sound prolongations
3. Broken words (pauses within a word)
4. Audible or silent blocking (pauses in speech)
5. Circumlocutions (word substitutions to avoid problematic words)
6. Physical tension
7. Monosyllabic whole word repetitions (I-I-I-I see him)
B. Causes anxiety about speaking. Functional impairment
C. Starts in early developmental period
D. Not due to neurological insult (e.g. stroke, tumour, trauma)
Tx: SLP

Question 4

8. 36 mo baby what is the best predictor of cognition?
   a) Gross motor
   b) Fine motor
   c) Social
   d) language
   - ————————–
9. Most correlated w future cognitive ability in a 30mo old?
   a. Gross motor
   b. Fine motor
   c. Language
   d. Social
   - —————————
10. Best predictor of cognitive development in 30 month old

Answer 4

Language

Central role as an indicator of cognitive = emotional development
Key factor in behavioural regulation + later school success

Question 5

11. What is the best way for a 7 year told to ride in the back of a car, in the middle seat with no head rest? (pictures shown taken from CPS statement)
    a. Forward facing car seat
    b. Booster seat with no back
    c. Booster seat with a full back
    d. Seat belt
    —————-
    Shows picture of 3 car seats (from CPS statement) – full restraints/tall car seat/booster seat. Question – 7 yo average size, going to sit in middle rear seat with no head restraint. Which one would be most appropriate?
    a. booster
    b. full restraint car seat
    c. tall car seat
    d. adult seat with restraints
    —————-
    Car seat question. Average wt of a 7 year old. Back seat has no head rest. They show you 3 pictures of car seats (from the CPS statement) and you have to pick the right one.

Answer 5

Booster seat with full back

Need to be 8yo, 36kg, 145cm to go from booster to seat belt
If seat has no head rest, need full back

Question 6

78. 57 lb (26kg) child. What car seat should you use?
    a. lap and shoulder belt with seat
    b. seat with built in restraint
    c. lap and shoulder belt, no airbag
    d. lap and shoulder with airbag

Answer 6

Lap and shoulder belt with seat = booster seat

Need to be 18kg to be in booster seat

Question 7

A 18 kg child is being transported in a car. Which of the following is the best restraint?

a. Car’s lap and shoulder belt
b. Car seat with its own restraining device
c. Car seat with the car’s restraining device

Answer 7

Car seat with car’s restraining device

Need to be 18kg to be in booster seat
Could consider forward-facing car seat with its own restraining device

Question 8

44. At what weight and age can a child start to use a front facing car seat?
    a. 9 kg, 9 mo
    b. 10kg, 12mo
    c. 18kg, 20mo

Answer 8

Stage 2

- at least 10kg, 1yo, can walk

Question 9

64. A child is ready to be transferred to a regular car seat. What is the minimum weight and height criteria for this to occur:
    a. 40kg and 150cm
    b. 40kg and 145cm
    c. 36kg and 145cm
    d. 36kg and 150cm

Answer 9

Stage 4

- at least 8yo, 36kg, 145cm

Question 10

Parents are concerned about a child’s performance at school. He has normal intellect. He is very clumsy and teachers mention that he has poor handwriting. He has difficulty hopping on one foot and seems to tire easily. He has normal strength on exam but low tone. Diagnosis is most likely:

a. Duchenne muscular dystrophy
b. Cerebral palsy
c. Developmental coordination disorder
- ——————-
39. 6 year old, teacher is concerned about his writing. He has always been clumsy and has some difficulty playing with his friends. Otherwise his development is normal. What is his most likely diagnosis
a. Developmental coordination disorder
b. ADHD
c. Autism

Answer 10

DCD

Question 11

41. A mother brings her 6 yr old son to your office with concerns that he has always been ‘awkward’. His teacher has commented on poor writing. On exam, he has normal power, low muscle tone and is unable to hop. Most likely diagnosis:
    a. Developmental coordination disorder
    b. Cerebral palsy
    c. Muscular dystrophy
    d. Tourette syndrome

Answer 11

DCD

Question 12

A 4 year old girl is referred to you for dysfluency. She grimaces when she stutters. What do you do?

a. Refer to SLP
b. Reassure
c. MRI head

Answer 12

Refer to SLP

Question 13

23. In a 5 month old boy, which would be the most concerning?
    a) Doesn’t turn to the sound of his own name
    b) Doesn’t sit upright without support
    c) Fisting of one of his hands
    d) Doesn’t smile all the time at his caregiver

Answer 13

Fisting in one of his hand >3mo is a red flag
Extreme handedness also a red flag
Needs potential neuroimaging

6 mo turn to name, sit in tripod, smile

Question 14

28. Child with expressive language delay and otherwise makes 12 piece puzzle, sociable. most likely to be associated with
    a) Reading difficulty
    b) Autism
    - —————————
29. 3 year old with expressive language delay, but everything else OK. What is he at risk for down the line?
    a. Reading disability

Answer 14

Reading difficulty

From Nelson’s: “Early language difficulty is strongly related to later reading disorder. Approximately 50% of children with early language difficulty develop reading disorder, and 55% of children with reading disorder were found to have early language difficulty”

Question 15

29. 2 ½ year-old girl who stutters. What would make you most concerned?
    a. Repeats whole word
    b. Repeats part of word
    c. Facial grimacing
    d. Pauses between words

Answer 15

Facial grimacing

Question 16

33 9 mo w an asymmetric tonic neck reflex. Cause?

a. CP
b. Normal

Answer 16

CP

ATNR that is seen in resting posture rather than being elicited is never normal!

ATNR

• triggered by turning H+N
• EXT of UE+LE on same side
• FLEX of UE+LE on opposite side
• disappears once baby can inspect things in midline (~6mo)

Question 17

35. Which one to refer?
    a. 18 mo with no words in a bilingual household

What are not causes of language delay? (6)

Answer 17

18mo with no words in bilingual household

NOT causes of language delay

1. twinning
2. birth order
3. “laziness”
4. multiple languages
5. tongue-tie
6. otitis media

Question 18

43. A 3.5 year old girl was referred to you for assessment. She speaks 50 words and 50% of her words are intelligible others. She points to things she wants. She can run well, can kick a ball, she can walk up and down stairs. She cannot throw a ball overhand. She can use a spoon. What is the MOST likely explanation of her symptoms?
    a. Hearing deficit
    b. Developmental delay
    c. Language delay

Answer 18

??Developmental delay

Expressive = 2yo
18mo = protodeclarative pt
GM = 2yo
Spoon = 2yo

Question 19

54. 3 yo with isolated language delay. What do you tell mom he is at risk for?
    a. Reading disability
    b. ADHD
    c. Articulation disorder.
    ————-
    Question about child with isolated language delay – what are they at risk for in the future?
    a. Dyslexia

Answer 19

Reading disability/dyslexia

Question 20

57. Question about kid with mild MR. Most likely etiology?
    a. Mom didn’t finish high school
    b. Cocaine
    d. Htn
    —————-
    Mild mental retardation is associated with:
    a. cocaine during pregnancy
    b. not finish high school
    ————–
58. Most predictive of mild MR?
    a. Maternal alcohol during pregnancy
    b. Cocaine during pregnancy
    c. Mom did not finish high school
    d. Neonatal hypoxia

Answer 20

Mother did not finish high school

Question 21

58. ## Two and half year old child who is using 50 words, not yet combining 2 word phrases, and barely intelligible 50% of the time. Motor skills gross intact.Boy is great at making lego designs, and building 12 piece puzzles. Only 50 words, and not putting two words together. Diagnosis?
    a. isolated language impairment

Answer 21

Isolated language impairment

Need to r/o hearing issue and assess for red flags of autism

Isolated expressive language disorder (i.e. late talker syndrome)

• M>F
• usually retrospective Dx
• have age appropriate receptive language + social ability
• once they start talking, speech is clear
• no increased risk for language or learning disability
• often have FHX or other males with similar developmental pattern

Question 22

61. how to diagnose expressive language delay in 2.5 year old (repeat)
    a. less than 100 words
    b. no 2 word combinations

Answer 22

No 2 word combinations

Question 23

62. 14 month old says specifically “dada” only. What other features make you worried about language delay?
    a. not responding to own name
    b. not babbling

Answer 23

Not babbling

If they have one word, should be babbling a lot
Not responding to own name is more concerning for autism

Question 24

65. Whom would you refer to speech and language therapy?
    a. 18 month old with no single word
    b. 6 y.o with phoneme problem
    c. 3 year old with 3 word sentences
    d. 4 yo with dysfluency
    ———
    Who to refer to SLP?
    a. 6 year old with trouble with phonemes
    b. no words by 18 months, in a bilingual household
    c. 2 year old, people only understand 50%

Answer 24

18mo with no single word

Question 25

67. 3.5 year old, follows 2 step commands, interested in communication, developmentally appropriate girl with 50% intelligible speech and repeats syllables and whole words. Most likely diagnosis:
    a. developmental dysfluency
    b. normal development
    c. delayed expressive language skills
    d. delayed receptive language skills

Answer 25

Delayed expressive language skills

But also delayed receptive language skills b/c at 3yo, should be following 3 step commands

Question 26

70. Which is an indication for urgent evaluation?
    a. baby does not turn to sound at 4 months
    b. baby does not babble at 6 months
    c. 15 mo old does not follow simple command without gesture
    d. 2 ½ year old without 2 word phrases

Answer 26

2.5yo without 2 word phrases

Question 27

77. 2.5 year old child who is not combining 2-words, has about a 50-word vocabulary and other people understand about 25%. Otherwise, climbs stairs, runs around, throws underhand. Interested in other people. What is this most consistent with?
    a. isolated language delay
    b. global developmental delay
    c. autism

Answer 27

Isolated language delay

Question 28

79. What is considered a developmental delay?
    a. no turning to name at 4 months
    b. no babbling at 6 months
    c. can’t follow single command without gesture at 15 months
    d. no 2 words together at 2 years

Answer 28

No 2 words together at 2yo

• turning to name and babbling start at 6mo
• single command without gesture 12-15mo

Question 29

83. 18 month old girl with delayed language. Points to things that she wants. Has two dolls that she loves to cuddle. What is her likely diagnosis?
    a. Isolated language delay
    b. Autism
    c. Asperger syndrome

Answer 29

Isolated language delay

Question 30

88. When to intervene
    a. 4 m.o. not turning to name
    b. 2.5 year old with no 2 word sentences
    c. 6 m.o. with no babble

Answer 30

2.5yo with no 2 word sentences

Question 31

103. Mother brings 4 year old child in to you worrying that they are delayed. Gross motor: stands on one foot momentarily, rides tricycle. Fine motor: draws circle, copies cross, Speech: counts to three, remembers 3 numbers, Social: washes hands, parallel plays
     a. 24 m
     b. 30 m
     c. 36m
     d. 48 m
     —————
     Mom’s worried about her 4-year old son being developmentally delayed. He can: Say his name and age. Stack 10 blocks. Draw a circle & copy a cross. Stand on 1 foot briefly. Parallel play. What is his developmental age?
     a. 24 mo
     b. 36 mo
     c. 48 mo
     —————
     A 4-year old child presents because his parents are concerned about his development. Developmental milestones:
     FINE MOTOR: Copies a cross and a circle
     GROSS MOTOR: Can balance on one foot for a few seconds.
     SOCIAL: Repeats 3 words from memory, able to count 3 objects.
     a. 18 months
     b. 24 months
     c. 36 months
     d. 48 months

Answer 31

GM: stands on one foot momentarily, tricycle = 3yo
FM: circle = 3yo, cross = 4yo
Speech: name, age, sex = 3yo
Social: parallel play = 2yo

36mo

Question 32

104. Which child would you send for further speech and language evaluation?
     a. 3 yr with dysfluency with repetitions of words and syllables
     b. a 2 yr old with 75 words and understood 50% by strangers
     c. a 6 year old with trouble with phonemes
     d. 18m from bilingual household with no words
     —————-
     Who should get referred to speech language pathology?
     a. 3 year old with occasional dysfluencies
     b. 6 year old with trouble with certain phonemes
     c. 18 month old from bilingual home with no single words

Answer 32

18mo from bilingual home with no single words

Question 33

105. Giving advice to parents about 4 month old with positional plagiocephaly. You would
     a. suggest they do neck exercises to prevent torticollis
     b. suggest child stay in car seat at home
     c. babe to sleep on their side
     d. encourage tummy time
     —————
     A 4 month old child is observed to have positional plagiocephaly. What do you recommend to the parents?
     a. encourage tummy time
     b. refer to neurosurgery to rule out craniosynostosis
     —————-
     121.A 4 month old child is observed to have positional plagiocephaly. What do you recommend to the parents?
     a. encourage tummy time
     b. refer to neurosurgery to rule out craniosynostosis

Answer 33

Encourage tummy time

10-15min 3X/d

Question 34

117. An infant can sit with a round back using his hands for support, can roll from prone to supine, stands with support, has a palmar grasp, laughs, and babbles. What is his most likely age?
     a. 3 months
     b. 6 months
     c. 8 months
     d. 12 months

Answer 34

6mo

Question 35

92. 20 month old with 3 words, points to pictures to book when asked to, mimics mother at works, stack two blocks. What is diagnosis?***
    a. global developmental delay
    b. speech delay
    c. hearing loss
    d. pervasive development disorder

Answer 35

Speech delay

Question 36

9. . You suspect a 3 year old female of having autism spectrum disorder. What diagnostic test would MOST likely reveal an abnormality?
   a. karyotype
   b. very long chain fatty acids
   c. fragile x testing
   d. chromosomal microarray
   - —————–
10. A 3yo girl has signs of autism. Which of the following studies would have the highest yield in finding a cause of her symptoms?
    a. Fragile X testing
    b. Karyotype
    c. Microarray
    d. Serum amino acids

Answer 36

Microarray

Question 37

98. 3 year old boy brought for assessment of developmental delay; features of autism: 3 words, no response to name, not interested in play, no identification of body parts, not pointing, wants to play with blocks only. Initial test?
    a. Hearing screen
    b. MR of head
    c. Psychometric testing
    ———————
    3 year old kid with very delayed language, no imaginative play, no reciprocal social interaction & some other developmental abnormalities. How to investigate first?
    a. audiology
    b. psych testing
    c. ?karyotype

Answer 37

Hearing test/audiology

Question 38

15. In a 15 month old infant, which of the following is the most indicative of an autism spectrum disorder?
    a. Not babbling frequently
    b. Not pointing to indicate interest

Answer 38

Not pointing to indicate interest

Question 39

25. 3 year old Girl with developmental regression and small head
    a) Rett

What are the features?

Answer 39

Rett

• MECP2 mutations
• female
  1. Regression. Normal development until ~1yo, then regression of language + motor. Then plateaus (not degenerative)
  2. Acquired microcephaly
  3. Repetitive hand-wringing and loss of purposeful + spont use of hands
• autistic behaviours
• gait abnormalities
• peculiar sighing resps with intermittent apnea +/- cyanosis
• GTC sz
• cardiac arrhythmias

Question 40

60. Suspected autism at 15 months. What feature most suspicious for autism at this age?
    a. hand flapping
    b. no single word at 15 months
    c. infrequent pointing for interest

Answer 40

Pointing for interest

More in keeping with the deficits in social communication + social interaction criteria of DSM

Question 41

71. 15 month old who only says a couple words, stereotypical play, does not engage in social play. What in your office is the best indicator of ASD?
    a. hyperactivity
    b. hand flapping
    c. does not point to objects to show interest
    —————
    15 mo old with only one word “mama” and difficult to engage during physical exam. At this age, what of the following is strongly associated with autism:
    a. hand flapping
    b. infrequent pointing and sharing interest
    c. no words
    —————
    Child suspected to have autism at 15 months. What would be a supporting feature of this diagnosis?
    a. doesn’t point for interest
    b. displays hand flapping
    c. preserved language development

Answer 41

Does not point to objects to show interest

Question 42

89. 18 month child with 3 words. What signs would be most characteristic of autism in a child of this age?
    a. hand flapping
    b. absence of pointing and gesturing
    —————-
    15 month who only says “ma”, stereotypical play, does not engage in social play. What is the best predictor of autism?
    a. Hyperactivity
    b. Hand flapping
    c. Does not point to things to show interest

Answer 42

Absence of pointing + gesturing

Question 43

96. Autism. Risk for recurrence?
    a. Slightly higher than general population
    b. Equal to gen population
    c. 50 % chance because AD
    d. non if avoids MMR
    - —————-
97. Mother with one child with autism, wants to know what recurrence of autism in second child will be?
    a. Same risk as general population
    b. Slightly increased risk
    c. 50% chance, as autism is autosomal dominant
    d. Risk will be reduced is child avoids MMR vaccine.

Answer 43

Slightly higher than general population

“There is a high recurrence risk (2-19%) for ASD among siblings”
Other RFs:
- closer spacing of pregnancies
- advanced mat/pat age
- <26wk GA
- FHx of LD, psychiatric d/o, social disability

Question 44

99. A couple wants to adopt a child from overseas, and brings a file for you to review. Which of the following would MOST likely be associated with other problems?
    a. Microcephaly in context of normal growth and weight
    b. Delayed speech with low weight
    c. Microcephaly in proportion to low height
    ————–
    A couple comes in to your office with asking for advice regarding the adoption of a child. Which scenario gives the worst prognosis?
    a. significant height and weight restriction.
    b. microcephaly proportionate to height reduction.
    c. significant microcephaly with normal height and decreased weight
    ————–
    113.Crazy adoption question describing parents who ask which child would be healthiest? 4 different complex scenarios given with various growth parameters.

Answer 44

Microcephaly with normal growth + weight

Peds in Review – preparing families for international adoption

• most children who are malnourished and poorly stimulated maintain brain growth, overtime HC may not be spared
• microcephaly is a red flag
• if microcephaly extreme or present from early infancy, may have other diagnoses other than malnutrition (FAS, genetic syndrome, perinatal brain injury)

Question 45

118. Which of the following is a sign of Asperger syndrome:
     a. gross motor delay
     b. preserved language development
     c. adequate social skills
     d. fine motor delay

Answer 45

Asperger no longer exists

Preserved language development

Question 46

2. a 3 year old boy is in your office. He is very energetic, aggressive and destructive. His height is on the 50th percentile and his weight on the 95th percentile. He is described as having a voracious appetite. He comes to see you and hugs you. He speaks in 1 word sentences. What is the diagnosis?
   a) Emotional deprivation
   b) Diencephalic syndrome
   c) Prader Willi syndrome
   d) ADHD
   ————————
3. Child with hyperphagia, disruptive in your waiting room, talking excessively, normal weight and hugs you repeatedly. Most likely diagnosis:
   a. ADHD
   b. Diencephalic syndrome
   c. Autism
   d. Psychosocial deprivation
   ————————
   Child that hugs you, very active in room, normal weight, voracious appetite. Diagnosis:
   a. diencephalic syndrome
   b. psychosocial neglect
   ————————
   Kid eats like crazy, very skinny, runs up to hug you. What does this kid have?
   a. diencephalic syndrome.
   b. emotional deprivation

Answer 46

Emotional deprivation

Question 47

94. 3y boy is in your office. Very energetic, aggressive and destructive, hugs the examiner. Voracious appetite. What is the diagnosis?
    a. ADHD
    b. Diencephalic syndrome
    c. Psychosocial deprivation
    ————————
95. A 2 y.o. child is active in the office, has good appetite at home, and hugs you.
    a. emotional deprivation
    b. diencephalic syndrome
    ———————–
    3 year old kid who’s really really active & destructive at home plus eats voraciously. In your office, he runs up & hugs you. Diagnosis?
    a. diencephalic syndrome
    b. emotional deprivation
    ——————–
    A 2-year old presents because is parents are concerned about his hyperactivity and uncontrollable behaviour. He has a voracious appetite. Through the history and physical exam he hugs you repeatedly. Most likely diagnosis?
    a. emotional deprivation
    b. diencephalic syndrome
    c. autism

Answer 47

Emotional deprivation

Diencephalic tumour

• causes hypothalmic optic nerve dysfunction
• FTT, severe emaciation, normal linear growth
• Emesis
• hyperalert, hyperactive, restless

Question 48

122. A 12 month old child has psychosocial deprivation. What is the most likely finding?
     a. poor appetite
     b. microcephaly
     c. normal development
     d. absence of cuddling response

Answer 48

Absence of cuddling response

Reactive Attachment Disorder
- poor hygiene
- poor motor coordination, often hypertonicity
- blank expression, eyes lack joy
A. Consistent pattern of inhibited, emotionally withdrawn behaviour toward adult caregivers
- rare/minimal seeking of AND response to comfort when distressed
B. Persistent social + emotional disturbance. >=2:
1. minimal social + emotional responsiveness to others
2. limited positive affect
3. Episodes of unexplained irritability, sadness, or fearfulness even during nonthreatening interactions with adult caregivers
C. Pattern of extremes of insufficient care. >=1:
1. Social neglect or deprivation - persistent lack of having basic emotional needs for comfort, stimulation + affection met by caregiving adults
2. Repeated changes of primary caregivers
3. Rearing in unusual settings that limit opportunities to form selective attachments
D. Doesn’t meet criteria for ASD
E. Evidence before 5yo
F. Child has developmental age of at least 1yo

Question 49

22 3 year old female, picky eater. Since 8 months of age, weight 15th percentile. Physical exam normal. Difficulties at mealtime specifically. Best option?

a. Allow kid to choose food.
b. Introduce child’s choice plus what family eats at mealtimes
c. cyproheptadine
d. Offer several small snacks throughout the day plus mealtimes

Answer 49

Parents choose food, kids choose how much they eat

No appetite stimlants - like cyproheptadine
No grazing with frequent snacks

Question 50

26. Boy with enuresis, what is a good non pharm way to treat it
    a) Positive reinforcement
    b) Bed Alarm
    c) Ddavp
    d) Bladder training

Answer 50

Bed alarm if motivated

Question 51

38. 8 year old boy with enuresis (did not tell you if it is primary or secondary or if it bothers him etc). What is the first step in management? [cps]
    a. Bed alarm
    b. Imipramine
    c. DDAVP

Answer 51

Bed alarm

Question 52

85. Which of the following has the lowest relapse rate when used for primary enuresis in a 7 year old boy?
    a. Imipramine
    b. DDAVP
    c. alarm system
    d. nighttime fluid restriction

Answer 52

Alarm system

Question 53

108 Etiology of primary enuresis as opposed to secondary:

a. holding urine during the day
b. family history
c. abuse

Answer 53

FHx

Question 54

47. 9 y girl’s parents separate/divorce. What do you expect from her? (CPS statement)
    a. She takes sides
    b. She wants them to get back together
    c. She blames herself

Answer 54

She takes sides

Question 55

93. Parents, children and divorce- what is true?
    a. males respond better to divorce in the immediate post divorce period than females
    b. Children do better in a 1 parent custody setting without seeing the other parent
    c. The best predictor of the child’s response is post separation parental conflict and depression rather than custody issues

Answer 55

The best predictor of the child’s response is post separation parental conflict and depression rather than custody issues

Children whose parents effectively share joint custody are better adjusted

Question 56

48. Kid talking well at home but refuses to talk at school. Normal development. What is your diagnosis?
    a. selective mutism
    b. language delay
    c. learning disability
    - ——————-
49. Child who doesn’t talk at school or make good eye contact with people. Including recess. Doesn’t have friends. At home speaks normally. Diagnosis
    a. Selective mutism
    b. Language delay
    c. Autism spectrum disorder

Answer 56

Selective mutism

• Present for >=1mo
• Hx of normal language in at least 1 situation to r/o any communication d/o, neuro d/o, ASD or schizophrenia
• Sx of underlying anxiety d/o (chronic pattern, not single traumatic event)
  Tx: fluoxetine + CBT

Question 57

50. A mom comes to see you about her 2 year old, previously well child. The child is having daily episodes where her trunk is writhing, and she becomes flushed and diaphoretic. She also grunts, and breathes rapidly during these episodes. Mom is sure she does not lose consciousness and if she talks to her daughter, she can shorten the duration of the episode. They happen when the child is in her car seat or watching tv. What is your next step?
    a. Refer to neurology for an EEG
    b. Upper GI to rule out reflux
    c) Reassure mom
    c. Refer to a psychologist
    —————-
    Child with recurrent episodes of flushing and writhing movements last for few minutes
    a. reassure
    —————–
    Child with episodes of flushing that are recurrent. Child doesn’t seem to be perturbed by episodes. Mom things they can be shortened if she intervenes. What to do? (repeat)
    a. reassure
    b. EEG
    c. start ritalin

Answer 57

Reassure

Self-stimulating behaviour + infantile masturbation

• infancy onward
• assoc’d with rhythmical rocking mvmt (hip flex + adduction), sweating, irregular breathing, grunting but no LO

Question 58

115. A 12 month old girl is referred for possible seizures. The infant has been observed by parents to have episodes of rocking movements, especially when she is bored. She does not lose consciousness during these episodes. She is developmentally appropriate for her age. What is the most likely diagnosis?
     a. self-stimulating behaviour/infantile masturbation
     b. infantile spasms
     c. myoclonic epilepsy

Answer 58

Self-stimulating behaviour/infantile masturbation

Question 59

56. 5 yr old with 21 yr old single mom. Teacher says she is hyperactive, hoarding food and not remorseful for inappropriate behaviour. No eye contact with mom, but runs up and hugs you. Most likely diagnosis?
    a. ADHD
    b. Autism
    c. Attachment disorder
    —————-
    5 yo girl born to mom who is now 21 yo. At kindergarten, noted to be hoarding food, hyperactive, speech delay, no remorse after hurting others. Does not make eye contact with mom but heads over to you. What is the likely cause?
    a. attachment disorder
    b. ADHD
    c. Oppositional defiant

Answer 59

Attachment disorder

Reactive attachment disorder
vs Disinhibited Social Engagement Disorder

Question 60

59. 30 month old child has been introduced to potty training. She has been encouraged to sit on potty after meals whether she can void or not. She has been doing it for one week. Now she is having temper tantrums every time you get her near the toilet. What is your advice on management?
    a. continue with current toilet training
    b. stop for 1-3 months and try again later
    c. punish her
    d. give treat every time she can sit on toilet quietly

Answer 60

Stop for 1-3mo and try again later

Question 61

73. Mom comes in wondering if her 2 year old is ready for toilet training. Of the following, which is most likely to show readiness?
    a. child motivated to please parents
    b. child able to follow two-step commands
    c. child has at least a 100 word vocabulary
    —————
    Signs of toilet readiness?
    a. able to dress and undress himself.
    b. desire to please based on positive relationship parents
    c. can stay dry overnight
    d. can communicated need for toilet using full sentences

Answer 61

Desire to please based on positive relationship with parents

Question 62

75. A 5 year old boy is having increasing difficulties with bad behaviour at school, including stealing objects. His parents have recently divorced and are having difficulties in their relationship. His mother would like advice on how to help with his behaviour. Best advice?
    a. take parenting classes and learn way to manage his behaviour
    b. you need to meet with both parents together to better assess the situation
    c. She needs to start disciplining her child ASAP
    —————–
    Marital troubles at home, child is acting out at school and daycare. Mom has come in for advice.
    a. give the mom parenting classes
    b. request a meeting with both parents to assess the home situation.
    c. give him ritalin
    —————-
76. A 5 year old boy is having increased difficulties with bad behaviour at school including stealing objects. His parents have recently divorced and are having difficulties. His mother would like advice on how to help with his behaviour. What would be the best advice to give her?
    a. Take parenting classes and learn ways to manage his behaviour
    b. You need to meet with both parents together to better assess the situation
    c. She needs to start disciplining her child as soon as possible

Answer 62

Meet with both parents together to better assess the situation

Question 63

Divorcing parents. What’s best for the kid?

a. best if joint custody could be given asap
b. best if child gets to see both parents (i.e. joint custody) even if the parents are fighting all the time
c. best if parents can settle their differences and not fight in front of kids

Answer 63

Best if parents can settle their differences and not fight in front of kids

Question 64

86. A 10 month old child has just started to bite his parents. Which statement is true?
    a. This is an early sign of possible autism spectrum disorder
    b. There may be an abusive situation in the family
    c. Baby is developmentally normal and he is excited
    d. The baby may be emotionally disturbed

Answer 64

Baby is developmental normal and he is excited

Biting can be due to teething or exploring new object with their mouth
As language improves, biting tends to lessen

• ~6mo: bite for discomfort (teething), most often parents
• ~12mo: bite when excited, most often close by caregiver/another child
• 15mo-3yo: bite when frustrated + want power/ctrl, bite other children
• > 3yo: bite when powerless or scared (losing a fight or think someone is going to hurt them). May indicate problems with expressing feelings or self control

Question 65

120. A 10 month old child bites you. Which statement is true?
     a. This is an early sign of possible autism spectrum disorder
     b. There may be an abusive situation in the family
     c. Baby is developmentally normal and he is excited

Answer 65

Baby is developmentally normal + is excited

Question 66

101. 7 year old girl still thumb sucking. What do you tell mother?
     a. Can lead to malocclusion and facial deformation
     b. Topical aversion therapy works well
     c. Reassure
     ————–
     7 yo boy who is still sucking his thumb. What do you tell parents
     a. can lead to malocclusion and facial deformity
     b. Is never associated with decreased self esteem
     c. Topical therapies are very effective

Answer 66

Can lead to malocclusion + facial deformity

Thumb sucking
- self-soothing behaviour
- If prolonged >5yo:
> paronychia
> malocclusion
> speech problems (lisping, T+Ds)
- Tx
- ignore, praise for substitute behaviours
- consider Tx only if very freq/great intensity (callus) >=4yo, asks for help to stop, teased, develop dental/speech problem

Question 67

112. Child slow at school because goes over every letter three times. What is the problem?
     a. Learning disability
     b. ADHD
     c. OCD

Answer 67

OCD

Question 68

116. A 2 year old child cries when mother is leaving for work everyday. She is also attached to a “special” teddy bear. What should be done?
     a. remove child’s teddy bear since this is abnormal attachment to an object
     b. reassure parents that this is normal separation anxiety appropriate for child’s developmental level

Answer 68

Reassure parents that this is normal separation anxiety appropriate for child’s developmental level

Many children use a transitional object (special blanket, stuffed toy), which functions as symbol of the absent parent.
Remains important until the transition to symbolic thought has been completed + the symbolic presence of the parent has been fully interalized

Question 69

6. A 10 month old baby wakes up every 2 hours and needs to be rocked back to sleep by his mom. What is the most likely cause?
   a) Benign rolandic epilepsy
   b) Sleep onset association disorder
   c) Night terrors

Answer 69

Sleep onset association disorder

Question 70

16. What is the first line intervention for sleep onset association type sleep disorder?
    a. Melatonin
    b. Stable bedtime routine
    c. Clonidine

Answer 70

Stable bedtime routine

Question 71

27. 18 month old won’t go to sleep, used to be breastfed at 12 months. What does he have?
    a) Sleep onset association disorder
    b) Nightmare
    c) Night terror
    d) Delayed sleep phase
    ——————
28. 18m old child falls asleep with his dad rocking him to sleep. However, he wakes up screaming multiple times per night. He will go back to sleep if calmed down, but often in his parents bed. He was breastfed to sleep for the first 12m. What is the issue?
    a. Sleep-wake-transition disorder
    b. Sleep association disorder
    c. Night terrors
    ——————
29. An 18 month old boy has difficulties waking up at night. He is rocked to sleep and then put in his crib. For the first year of life he was breastfed until he fell asleep. What is the cause of his sleeping problems?
    a. Sleep wake transition disorder
    b. Sleep association disorder
    ——————–
30. 18 mo old, wakes up throughout the night, needs parents to console. Ends up sleeping in parents bed. (repeated)
    a Sleep wake transition disorder
    b) Sleep onset association disorder
    c) Night terror
    d) Nightmares

Answer 71

Sleep onset association disorder

Question 72

68. Child wakes up about 1 hour after sleep, cries out for parents, upset. Never wakes up after midnight. Falls back asleep by herself. No recollection in AM. Diagnosis?
    a. Nightmares
    b. Sleep onset association disorder (SOAD)
    c. Night terrors
    d. Circadian Rhythm disorder
    ————–
    Child has frightening awakenings, screams, cries. No recollection in the morning. What is the most likely diagnosis?
    a. nightmares
    b. night terrors

Answer 72

Night terrors

Question 73

52. 18 month boy, wakes up 1-2 hours after going to bed, screaming, difficult to arouse, is confused and diaphoretic. Likely cause?
    a. nightmares
    b. night terrors
    c. seizures
    —————-
    Child has recurrent episodes of sudden crying, frightening episodes, unaware. Diagnosis?
    a. night terrors
    b. night mare

Answer 73

Night terrors

Question 74

36. 4y girl w night terrors every night at midnight. What do you advise the parents?
    a. Reassure the parents
    b. Wake up kid 15 min before for half hour

Answer 74

Wake up kid 15min before for half hour

Sleep terror

Question 75

55. At what age should a child be able to self-soothe when he awakens at night?
    a. 5-7 months
    b. 8-10 months
    c. 11-13 months
    d. 14-17 months

Answer 75

5-7mo

Infants (2-12mo)

• Total sleep: 12/d. 9H at night, 3H for naps
• ability to self soothe develops in first 3mo
• ability to consolidate sleep (sleep through night) develops 1.5-3mo
• Problems:
  1) sleep onset assoc’n d/o

Toddler (1-3yo)

• Total sleep: 12H. 10H at night, 2H naps
• At 18mo, go from 2 to 1 nap
• nighttime fears develop. Transitional objects, bedtime routine important
• Problems:
  1) sleep onset assoc’n d/o
  2) limit setting behavioural insomnia of childhood

Preschool (3-5yo)

• Total sleep: 10H, no nap
• sleep problems can become chronic
• Problems:
  1) limit setting behavioural insomnia of childhood
  2) Nighttime fears/nightmares
  3) OSA

Middle childhood (6-12yo)

• Total sleep: 10H
• sleep problems -> school + behavioural problems
• irregular routine, screen time
• Problems
  1) OSA
  2) insufficient sleep

Adolescent (>12yo)

• Total sleep: 7H (recommended 9H)
• puberty-mediated phase delay (later sleep onset + wake)
• Problems
  1) Delayed sleep phase d/o
  2) Insufficient sleep
  3) Narcolepsy
  4) Restless leg syndrome/periodic limb movement d/o

Question 76

119.A three year old child wakes at midnight each night. He screams and cannot be consoled. He then falls back asleep on his own. He has absolutely no recollection of events in the morning. The parents’ sleep is significantly disturbed and they are asking for advice. What do you recommend?
a. discipline the child as this is unacceptable
b. stop his afternoon nap
c. start a reward chart system and give rewards for nights when he does not wake up
d. wake him up 15 minutes before midnight for 7 days in a row
——————
69. A child is having episodes of waking up about an hour after falling asleep, inconsolable screaming lasting 5 minutes, and then returning to bed. Does not remember in the morning. Parents are at their wits end and getting no sleep. You suggest?
a. wake child at 11:45 pm and keep awake for 10 minutes X 7nights in a row
b. reassure parents
c. stop afternoon naps
d. start a reward chart system for nights he doesn’t wake up
————-
Child wakes up every night, ++ scared and screaming, no recollection in the
morning. Parents are tired and frustrated. What to do?
a. wake him up 11:45pm every night for a week
b. prescribe a benzodiazepine
c. refer to psychiatry
————–
107. A three year old child wakes at midnight each night. He screams and cannot be consoled. He then falls back asleep on his own. He has absolutely no recollection of events in the morning. The parents’ sleep is significantly disturbed and they are asking for advice. What do you recommend?
a. discipline the child as this is unacceptable
b. stop his afternoon nap
c. start a reward chart system and give rewards for nights when he does not wake up
d. wake him up 15 minutes before midnight for 7 days in a row

Answer 76

Wake him up 15 minutes before midnight for 7 days in a row

Sleep terror

Question 77

114. 8 month old baby is not sleeping through the night. She is waking up one hour after being put down in her crib. Which of the following is true:
     a. this should improve if she learns to fall asleep in her crib vs. being rocked to sleep
     b. she should be allowed to cry to sleep to solve this problem
     c. giving the baby a pacifier is a proven technique
     d. she should be given a bottle of warm milk to help her fall asleep in her crib

Answer 77

This should improve if leans to fall asleep in her crib

Put down while drowsy but still awake

Question 78

12. A mom brings in her son for concerns around his school performance, but feels he is cognitively normal. He has trouble with reading, and has trouble understanding when he reads to himself. His teacher has been spending more resource time with him, and when she reads aloud to him, he understands well. What is the most likely diagnosis?
    a. Myopia
    b. Dyslexia
    c. General learning disorder
    D. Speech apraxia
    ——————
13. 8 yr old boy is brought to you because of “difficulties learning”. he has difficulties finding words and with some pronunciation. he does not comprehend what he reads. however, he understands when his parents read to him. What is the most likely diagnosis?
    A. aspergers
    B. specific language impairment
    C. verbal apraxia
    D. dyslexia
    ——————
14. Young boy is having trouble at school with reading. Cannot read out loud and has trouble understanding when he reads to himself. He seems to understand well when read to by the teacher.
    a. learning disability
    b. expressive language delay
    c. dyslexia
    ——————
15. Child who cannot read, but understands when read to. Doing poorly in all subjects. Diagnosis?
    a. Dyslexia
    b. Expressive aphasia
    ——————
    111.. 7 yo male with normal intelligence is struggling at school. He cannot read aloud and doesn’t understand reading material but can learn when read to. What is the cause?
    a. ADHD
    b. Expressive aphasia
    c. Global delay
    d. Dyslexia

Answer 78

Dyslexia

• No longer in the DSM. Now grouped under Specific Learning Disability
• difficulty with processing sounds of speech (phonics) -> difficulty in breaking down words into smaller units of sound (phonemes)
• Difficulties with accurate +/ fluent word recognition and by poor spelling + decoding abilities
• Unexpected in relation to other cognitive abilities + in context of effective classroom instruction
• Results in secondary problems of poor reading comprehension + poor vocab
• strong FHx
• ***Most SN test: timed reading test
• Tx: SLP to work on phonics then fluency
• Lifelong, may need accomodations
• Co-occurs with ADHD

Question 79

A child is referred to you for assessment of a learning disability. What do you do?
a. Refer for psychoeducational testing

Answer 79

Refer for psychoed

Question 80

30 12 year old boy with school difficulties. Teacher thinks he has a learning disability. Your history and physical exam are negative. What would you do?

a. CBC, lead levels, TSH
b. Start Stimulant
c. Send to psychology
d. Assess short term memory and fine motor skills

Answer 80

Send to psychology

• Ideally send for vision + hearing
• Diagnostic criteria for specific learning disorder are met based on clinical synthesis of individual’s history, school reports, & psychoeducational assessment
• If suspect intellectual disability with normal Hx & PEx, CBC & TSH are part of the Tier 1 metabolic screen tests, but first line is microarray & Fragile X.
• Only do lead levels if Hx of exposure
• ADHD requires concerns in different environments
  Assess short term memory & FM skills wouldn’t lead to a diagnosis

Question 81

49. Child with concerns LD what to test
    a. psychoeducational
    b. CBC
    c. lead levels

Answer 81

Psychoeducational assessment

Question 82

87. Mother has questions about her 5 year old sons’ performance at school. She is concerned that he will have reading problems because his father had significant problems with reading. Of the following which predicts a future difficulty with reading:
    a. Delayed walking
    b. Delayed language milestones

Answer 82

Delayed language milestones

Question 83

90. 30m old with 50 words otherwise normal. No history suggestive of autism. What would you tell mom that he at risk for:
    a. Reading problems
    b. autism
    c. ADHD

Answer 83

Reading problems

From Nelson’s: “Early language difficulty is strongly related to later reading disorder. Approximately 50% of children with early language difficulty develop reading disorder, and 55% of children with reading disorder were found to have early language difficulty”

Question 84

102. Child sent to you for assessment of failing academic stuff, teacher wanted to know if there is a LD. Hx and physical normal. What do you do now?
     a. Psychology assessment
     b. lead levels
     c. Get tutor
     d. TSH

Answer 84

Psychology assessment

Question 85

3. A 10 year old boy with previously repaired TAPVD comes to your office with symptoms of ADHD. He is on no medications currently and has been well. Your next best step is:
   a) Start stimulants
   b) ECG
   b) Refer to psychiatry
   d) Continue to monitor

Answer 85

Start stimulants

CPS:

• little evidence that taking meds further increases risk of sudden cardiac death
• TOF + dTGA (esp post Senning + Mustard) is assoc’d with sudden death
• PCP should do H+P on all to identify those are risk of sudden cardiac death
• NO routine ECG before starting meds
• If no known heart disease, PCP decides on the meds
• If known heart disease followed by cardiologist, PCP + cardio make consensus decision by discussion. Cardio doesn’t need to see in person before ADHD med.
• Refer to cardio before starting meds if newly suspected heart disease or identified RFs for sudden death on H+P

Question 86

34. Boy w hx of TAPVR, now has ADHD. You think he would benefit from stimulant medication. What is your next step? [cps]
    a. Hx+ physical then referral to cardiology
    b. Refer immediately to cardiology

Answer 86

H+P then refer to cardiology

Question 87

4. Which of the following would be the most helpful in confirming the diagnosis of ADHD in a 12 year-old male
   a. Symptoms are only at school
   b. Difficulty making friends
   c. Forgets his homework at school
   d. Spends a lot of time playing video games

Answer 87

Forgets homework at school

Question 88

14. Boy with new diagnosis of ADHD and use drugs. What ADHD meds to prescribe?
    a. Vyvanse
    b. Amphetamine slow release (Ritalin)
    c. Dextroamphetamine
    ——————–
    Kid with Hx substance abuse. Needs medication for ADHD. Whis is BEST option?
    a) Vyvance
    b) Methylphenidate IR
    c) Guanfacine
    d) Ritalin SR
    ———————-
    A teenage boy with addiction issues is diagnosed with ADHD. His mother is concerned about the potential for abuse with some ADHD medications. Which stimulant do you start him on?
    a. Concerta XR
    b. Ritalin
    c. Vyvanse

Answer 88

Vyvanse

• lasts 13-14H
• capsules can be opened + diluted in water
• because of its pro-drug design, its delivery curve is not changed by mode of administration (oral, inhalation, or injection), which reduces its possible abuse potential
• Lisdexamphetamine = Vyvase, is prodrug to dexamphetamine = dexedrine
• Non-stimulants like atomoxetine or guanfacine do not have abuse potential

Question 89

37. What do you tell mom of an ADHD kid on stimulant medication? [cps]
    a. It will decrease the risk of drugs dependency

Answer 89

It will decrease the risk of drugs dependency

Children with ADHD have higher risk of substance abuse vs those without ADHD
Children with ADHD who are treated with medication have lower risk of substance abuse vs untreated

Non-stimulants like atomoxetine or guanfacine do not have abuse potential

Question 90

51. A 13y.o. boy with ADHD is taking 36mg of Concerta. His symptoms and school performance have improved and his mother is happy with his improvements. For the past 2 weeks, however, he has been sad, often crying unpredictably. He also is having difficulty falling asleep at night. What is the next best step in his management?
    a. Decrease the dose of Concerta to 28mg
    b. Change from Concerta to Adderall
    c. Add fluoxetine
    d. Add melatonin
    —————–
    Child who you are following for ADHD, and started treatment 2 weeks ago. Mom tells you he has done really well at school, and his grades started to improve. Side effects of difficulty sleeping, sad moments, moody, and poor appetite. His current dose of medication Concerta 36mg x 7 days. What do you do?
    a. decrease his Concerta dose to 27mg
    b. add fluoxetine
    c. add melatonin
    d. change to Adderall

Answer 90

Change from Concerta to Adderall

80-90% Respond to stimulants
1) Methylphenidate based: Ritalin, Biphentin, Concerta
2) Amphetamine based: Adderall, Vyvanse
70% respond equally well to either
30% Respond preferentially to one class (benefits +/ SEs)

Question 91

74. Teenage girl with severe ADHD. Started on Concerta 36 mg. Medicine is working great for her ADHD, but on follow-up noted to have lost 10 pounds. What would you do?
    a. switch to strattera
    b. decrease concerta to 5 days/week from 7 days/week
    —————
    Teen with ADHD, 14 lb weight loss. Currently ADHD is better controlled on his
    long-acting ADHD med. What is the best thing to do? (repeat)
    a. start Straterra
    b. Consult a psychiatrist
    c. Change from 7 days a week dosing to 5-days a week.
    —————
    10 yo girl with ADHD on Concerta 35mg comes after 3 months with 4kg weight loss. What do you do?
    a. Decrease Concerta to 5 times a week
    b. Change to Strattera
    ————–
75. Adolescent female on extended release ritalin for ADHD. Takes it 7 days/week. Has had improvement in school performance with med. Has lost 15 lb in last 3 mo. How to manage?
    a. decrease use to 5 day/ week
    b. change to strattera
    ————–
    Adolescent female with ADHD and slightly decreased mental capabilities presents with school difficulties. She is started on concerta 36 mg OD x 7 days/week. At follow-up 3 months later she has lost 15 pounds. What would be you management?
    a. Decrease Concerta to 5 times per week
    b. Discontinue concerta and start strattera
    c. Refer to psychiatry

Answer 91

Switch to straterra

80-90% Respond to stimulants
1) Methylphenidate based: Ritalin, Biphentin, Concerta
2) Amphetamine based: Adderall, Vyvanse
70% respond equally well to either
30% Respond preferentially to one class (benefits +/ SEs)