Development // Psych - 2019 Updated!

Question 1

Baby can transfer a rattle hand-to-hand, sit with a rounded back using hands for support. What is
his age:
1. 3 months
2. 4 months
3. 6 months
4. 9 months
5. 12 months

Answer 1

3. 6 months
   - most primitive reflexes gone, sits in tripod, shakes rattle, holds cube with 2 hands, vocalizes to give answers, bangs cubes together

Question 2

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.

a) 3 months
b) 6 months
c) 8 months
d) 9 months
e) 12 months

Answer 2

b) 6 months

Question 3

What is true of a normal 9 month old child?

1. just acquired palmar grasp
2. says mama/dada and one other word
3. has object permanence
4. has names for objects

Answer 3

3. has object permanence

Major milestone achieved by 9 months

Question 4

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 4

c) Baby is developmentally normal and he is excited

Everything goes into the mouth at 6 months; lots of kids bite during play

Question 5

Which is the most characteristic of a 9-12 month old?

a. object permanence
b. imitates scribbling
c. transfers objects from hand to hand
d. uses mama and dada specifically

Answer 5

ANSWER: d. uses mama and dada specifically

a. object permanence - have by 9 months
b. imitates scribbling - 18 months
c. transfers objects from hand to hand - starts at 6 months

Question 6

All of the following are true about development EXCEPT:

a) walk 3 steps at 15 months
b) copy horizontal line at 15 months
c) stack 3 blocks at 18 months
d) speak 10 words at 18 months
e) climb stairs holding rail at 18 months

Answer 6

ANSWER: b) copy horizontal line at 15 months - “makes line with a crayon” at 15 months, but
“imitates vertical stroke at 18 months and horizontal stroke at 24 months”

a) walk 3 steps at 15 months - yes, should walk alone by 15 months
c) stack 3 blocks at 18 months - yes, should do this at 15 months
d) speak 10 words at 18 months
e) climb stairs holding rail at 18 months - yes, climbs stairs with one hand held

Question 7

A picture of child showing the parachute reflex is shown. What is true?

a) This is a primitive reflex that disappears by 4 months
b) This is a voluntary reflex which disappears when child starts walking
c) This is an involuntary reflex that appears at 7-9 months and does not disappear

Answer 7

c) This is an involuntary reflex that appears at 7-9 months and does not disappear

Need parachute reflex to start walking so if you fall you don’t smash your face; it doesn’t go away (so you keep not face smashing)

Question 8

Which is the indication for urgent evaluation?

a. Baby does not turn to sound at 4 month
b. Baby no babble at 6 mo
c. 15 mo does not follow simple command without gesture
d. 24 m without 2 word phrases

Answer 8

ANSWER: a. Baby does not turn to sound at 4 month

b. Baby no babble at 6 mo - should babble at 6 months, but not red flag if not
c. 15 mo does not follow simple command without gesture - 12 months should follow 1 step
command with gesture, 14 months should follow 1 step command without gesture
d. 24 m without 2 word phrases - should have 2 word phrases at 2 years

Question 9

A child is seen with her mother. The child reportedly wakes to loud noises. She stops crying when comforted by her mother. She makes some cooing and gurgling noises and is feeding well. When prone she is able to lift her head off the surface. When she is held up against her mother’s shoulder she lifts her head off the shoulder. She is not yet putting weight on her forearms when in prone. She is not yet holding her head steady when in a sitting position. The developmental age of the child is:

a) 2 weeks
b) 4 weeks
c) 6 weeks
d) 8 weeks
e) 10 weeks
f) 12 week

Answer 9

ANSWER: d) 8 weeks= Nelsons= raises head sustained on ventral suspension, head lag when pull to sitting, follow objects, smile with contact, listen to voice + coo

f) 12 week= 3 mon= lift head with arm extended, waves at toys, head lag partially compensated, moro gone, sustained eye contact and says “aah, ngah”

Question 10

A little boy is brought in by his father. He responds to having his name called, smiles and babbles when you speak with him. He squeals with delight when bounced on his father’s knee. He grabs at a toy and puts the toy to his mouth When in prone he is able to push up on his hands and hold his head steady. He then rolls onto his back. In a sitting position he leans forward and puts some weight on
his hands. He not yet sitting unsupported. He is not picking up small items with thumb and first finger. The developmental stage is:
a) 2 months
b) 4 months
c) 6 months
d) 8 months
e) 9 months

Answer 10

c) 6 months

Question 11

A child visits your office with her mother. She brings a doll and her purse with her. She asks her mother “where is my cookie?”. She tells you “I went to Allison’s birthday party. I wore my pink Sleeping Beauty dress, we had a fashion show and we made a wand craft. I am having a Dora birthday and all my friends are coming.” Her party is in 2 days. She easily imitates drawing a circle and cross, but has trouble with a square. She is happy to pretend to examine her doll with your stethoscope while you talk to her mother. How hold will this child be at her birthday party?

a) 3 years
b) 4 years
c) 5 years
d) 6 years

Answer 11

b) 4 years = at least 3 given circle, cross but not quite 4 y.o. milestones so next birthday party is

Question 12

The average 2 year old has the following developmental milestones?

a) Vocabulary of 100 words
b) Speaks in 2 word sentences
c) Follow 2 step commands
d) Clear articulation
e) 1 and 2

Answer 12

e) 1 and 2

a) Vocabulary of 100 words= YES should have by 18-24 month
b) Speaks in 2 word sentences = YES should have by 18-24 month
c) Follow 2 step commands= attained usually between 24-36 month
d) Clear articulation -> 90% in 4 y.o. and 100% in 5 y.o.
e) 1 and 2

Question 13

A girl comes to your office, she walks into the room independently and squats to pick up a ball and follows the direction “throw me the ball” when you ask. She says dada and mama for dad and mom and baba for bottle and says “all gone” or “uh oh” in the exam room. When asked “where is your nose, eyes and head” she points appropriately. She points to a ball and says “ba”. She says “mo” to request more cheerios. She makes good eye contact. She stack 3 small blocks. When she leaves
the exam room she waves bye-bye. What is her developmental age?
a) 10 months
b) 12 months
c) 15 months
d) 18 months
e) 20 months

Answer 13

d) 18 months

-Gross Motor: walk (12 mon), squats (< 2y.o.)
-Fine Motor: throws (min. 12 months), 3 tower (min. 12 month since agex3= # cubes in tower)
-Speech: specific mama and dada (12 month minimum), points (15 month), follow simple command
(15 months). Not quite 2-3 word phrases = 2 y.o.
-Social: knows body parts (18 month),

Question 14

Which milestone do most children achieve first?

a) Overhand throw of a ball
b) Kicking a ball
c) Hopping
d) Riding a tricycle
e) Skipping

Answer 14

b) Kicking a ball (18 month)

a) Overhand throw of a ball (2 y.o.)
b) Kicking a ball (18 month)
c) Hopping (4 y.o. hops on one foot)
d) Riding a tricycle (5 y.o.)
e) Skipping ( 5 y.o.)

Question 15

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 15

b. no words by 18 months, in a bilingual household

refer to SLP if: not using 3 words at 15 months

Question 16

Delayed 4 y/o. Can go up and down stairs one foot at a time. Three word sentences. Vertical lines, no circle. 50 words. What is his developmental age.

a. 18
b. 24
c. 30
d. 36

Answer 16

c. 30

Vertical line at 18 months, circle at 3 years, 3 word sentence at 2-3 years, alternating feet on stairs at 3 years

Question 17

Name 1 milestone in each of the following criteria for a 36 month old: 1 line each

a) gross motor
b) fine motor
c) language
d) social

Answer 17

a) gross motor – tricycle, stairs alternating feet, stands on one foot briefly
b) fine motor – 9 block tower, circle, uses utensils, undresses
c) language – 3 word sentences, 250 words, 75% intelligible, full name, age, gender
d) social- group play, shares, knows name and age
e) Cog: shapes, compares 2 items, counts to 3

Question 18

Write “normal” or “abnormal” for an 18-month old child that you are assessing in your office?
Has 2 words
Walked at 14 months and is unable to go up and down stairs
Doesnʼt point to things
Displayed a hand preference at 10 months of age

Answer 18

Has 2 words – abnormal (should have 7-20)
Walked at 14 months and is unable to go up and down stairs - normal
Doesnʼt point to things - abnormal
Displayed a hand preference at 10 months of age – abnormal

Question 19

Kid is 10 months old, ex 28 weeker. What is developmental age. Sitting independently for 10 min, could roll over, not yet cruising, no pincher grasp. Babbled. Not pulling to stand. Look for dropped objects briefly.

Answer 19

Sitting independently for 10 min (6-8m) , could roll over ( 6-8mo) , not yet cruising ( 9-11m) , no
pincher grasp (9-11m). Babbled (6-8mo). Not pulling to stand (9-11). Look for dropped objects
briefly. (9-11m)
- cGA 7 months, developmental age 6-8m

Question 20

Child who is 2 years old. Speaks 8 words. Points and gestures. Socially appropriate. What is the most likely diagnosis:

1. Global developmental delay
2. Developmental language disorder
3. PDD

Answer 20

2. Developmental language disorder

Question 21

A 3 year old child is seen in your office. He just started making 2 word sentences and has about a 50 word vocabulary. His receptive language is better than his expressive language. He can build a tower of 12 blocks and make a very nice house out of Legos. What do you counsel the mother that he is at risk for in the future:

a. Autistic spectrum disorder
b. Developmental disorder
c. Reading disorder
d. ADHD

Answer 21

c. Reading disorder (yes! strong association (50%) between language disorder and later reading disorder)

Question 22

A mother is concerned that her 3-year-old child was able to speak 3-4 words sentences at 22 months of age but now she seems to be stammering/having dysfluency of speech a lot. What next:

a) reassure
b) audiology testing
c) refer to speech pathologist
d) complete neurodevelopmental assessment
e) emotional disturbance can be the cause of stammering

Answer 22

a) reassure - developmental disfluency - common between 2-3 years, lasts weeks to months and resolves by age 4 without treatment; child is not frustrated or distressed versus stuttering they are

If they specifically were talking about stuttering, usually onsets between 4-5 years, multiple repetititions common (more severe than dysfluency), and needs referral to SLP (of note, can be caused/worsened by emotional disturbance)

Question 23

7 yo boy with past history of speech delay. His reading is now below a grade 1 level. Teacher thinks that he has ADD. What would be the most appropriate next step:

a) investigate for learning disability
b) psychotherapy
c) behavior therapy
d) Ritalin 5mg bid
e) Ritalin 20 mg bid

Answer 23

a) investigate for learning disability

Early language disorder is strongly associated with reading disorder

Question 24

In a child with expressive speech delay, the parents should be encouraged to all of the following except:

a) read to him at night
b) make him repeat incorrectly pronounced words over and over
c) make him stop his activity and look at you when you talk
d) don’t complete his sentences

Answer 24

b) make him repeat incorrectly pronounced words over and over

Question 25

A 2 year old boy has only 3 single words, he has poor receptive language, does not point to indicate his wants, does not orient to his own name and does not engage in pretend play. He loves to play with his blocks. Which of the following is important in your investigation of his problem:

a. Psychological assessment
b. MRI head
c. Speech/language assessment
d. Audiology testing

Answer 25

d. Audiology testing

Sounds like autism, but always need to rule out hearing impairment

Question 26

You are seeing a 3 year old girl for language delay. While her mother is talking she wanders around your exam room. She says ‘go out’ to her mother. She puts her mothers hand on a toy to get her to fix it. She does not respond when you call her name. Of the following history items, which would assist you to make your diagnosis?

a) Recent family stressors
b) Family history of delayed language
c) Description of her social interactions with family and children at daycare
d) Resuscitation history after birth

Answer 26

c) Description of her social interactions with family and children at daycare

She be autistic

Question 27

2½-year-old child is referred with language delay and inferior ectopia lentis. You should

a) molecular studies for Marfan syndrome
b) echocardiogram to rule out aortic root abnormalities
c) fibroblasts/skin biopsy for enzyme assays
d) quantitative serum amino acids
e) platelet count and coagulation studies for hypercoagulability

Answer 27

d) quantitative serum amino acids

homocystinuria: mitral valve prolapse, tall stature, long bone overgrowth, developmental delay
diagnosis: elevated methionine or homocystine in body fluids (including blood and urine) are diagnostic, cystine is low or absent in plasma
- can do liver biopsy to look for the enzyme

Question 28

All of the following are true of vision in newborn infants EXCEPT:

a) should be able to fix on a large object from birth
b) by 2 months of age the infant can follow through 180 degrees
c) retinal hemorrhages are rare in newborns and cause permanent deficits
d) a newborn’s sclera is thin which causes a blue hue

Answer 28

c) retinal hemorrhages are rare in newborns and cause permanent deficits

• superficial retinal hemorrhages may be observed in many newborn infants
• the majority resolve within 2 weeks
• complete resolution of all birth related hemorrhages expected between 4-6 weeks

Question 29

Which is true regarding children in foster care:

1. In older kids, occasional visits with parents is warranted if child previously had developed a strong attachment to parents
2. Disruption of continuity of care may be potentially detrimental to all children
3. If they are in a loving foster home for their first year of life, they will do well long term
4. Child should be placed with grandparents for best long-term outcome

Answer 29

? 2. Disruption of continuity of care may be potentially detrimental to all children (a little too strong to say ALL)

? 1. In older kids, occasional visits with parents is warranted if child previously had developed a strong attachment to parents (this is what our system does currently)

unpredictable contact with parents, and placement changes negatively impact child’s health

Question 30

1-year-old child with psychosocial deprivation. Which is the most likely finding:

a) poor appetite
b) parental history of inadequate caloric intake
c) microcephaly
d) normal development
e) absence of cuddling response

Answer 30

e) absence of cuddling response

Question 31

A mother of a 9 yo boy visits you in your office. She would like to know what the effects of her separation and impending divorce will have on her son. The statement that you are most likely to include in your discussion with her would be:
a) If the mother and son undergo psychological counselling the effects of the separation and
divorce will likely be short-lived.
b) Males adjust better than females in the immediate period after divorce.
c) Joint custody is better for the child regardless of whether there is continued conflict between the parents.
d) Parental depression and conflict issues will more likely determine the adjustment of the child than custody issues.
e) The most important issue to address at this time is custody.

Answer 31

d) Parental depression and conflict issues will more likely determine the adjustment of the child than custody issues.

3 most significant factors impacting child’s well being during a divorce:

• quality of parenting
• quality of parent-child interaction
• degree, frequency, intensity and duration of hostile conflict

Question 32

Of the following behavioral phenotypes, which describes Williams Syndrome (7q11.23 deletion)?
a) Strengths in verbal short term memory, extreme weakness in visual-spacial skills, excessive
talking, hyperacusis, inattention, phobias and sleep problems
b) Depression, shyness, social anxiety, executive function deficits, cognitive decline and dysinhibition
c) Delays in motor and language skills, mild cognitive impairments or learning disabilities, and obsessive compulsive characteristics
d) Severe cognitive impairments, minimal verbal communication, movement or balance disorder,
easily excitable

Answer 32

a) Strengths in verbal short term memory, extreme weakness in visual-spacial skills, excessive
talking, hyperacusis, inattention, phobias and sleep problems

NOTE: c) Delays in motor and language skills, mild cognitive impairments or learning disabilities, and obsessive compulsive characteristics (Usually more ADHD, GAD)

Question 33

You are seeing an 18 month old boy with Fragile X syndrome. Which of the following developmental issues would not be seen in boys with a full FMR mutation?

a) Delays in fine and gross motor skills
b) Relatively strong expressive communication
c) Cognitive impairments
d) Hyperactivity and distractibility
e) Social avoidance and anxiety

Answer 33

b) Relatively strong expressive communication (usually delayed speech by 2y.o.)

Question 34

You are seeing a 3 year old boy with his foster parents. There is a confirmed history of prenatal alcohol consumption. Which of the following physical findings would support a diagnosis of FAS?

a) Weight at 50 th percentile
b) Height at 50 th percentile
c) Philtrum length at <3 rd percentile
d) Palpebral fissure length <3 rd percentile
e) Head circumference at 25 th percentile

Answer 34

d) Palpebral fissure length <3 rd percentile

Question 35

Of the following syndromes with tall stature, which does not have MR as part of the presentation?

a) Fragile X
b) Sotos Syndrome
c) Karyotype XYY
d) Marfan’s Syndrome
e) Homocysteinuria

Answer 35

d) Marfan’s Syndrome

Karyotype XYY: (Jacob’s tall and possible LD and behavioural/aggression; and extra note:
XXY- tall stature called Klinefelter also at risk for LD)

Question 36

What syndromes are on the differential diagnosis for a child with tall stature and developmental of behavioural abnormalities?

Answer 36

Klinefelter, fragile X, homocysteinuria, Loeys-Dietz, Sotos, Weaver syndrome

Question 37

What’s the syndrome? ● Tall stature, Gynecostmastia, delayed puberty, infertility, small firm testes, high pitched voice, LD

Answer 37

Klinefelter (XXY)

Question 38

What’s the syndrome? Tall stature, ● large head, long thin face with receding hairline
● feeding difficulty since birth with facial flushing and hypotonia.
● High palate and pointy chin

Answer 38

Sotos syndrome (5q35 deletion)

Question 39

What’s the syndrome? ● marfan-like habitus, developmental delay, inferior subluxation of lens , cataracts, crowding of teeth

Answer 39

Homocysteinuria

Question 40

You are asked to consult on a newborn with congenital anomalies. The child has a coloboma of
the iris, TOF, choanal atresia, dysplastic low set ears. The pregnancy and family history are
unremarkable. The karyotype is normal and FISH for microdeletion of 22q11 is negative. What is the
most likely diagnosis?
a) Cornelia de Lange
b) Williams Syndrome
c) Noonan Syndrome
d) Vater association
e) CHARGE syndrome

Answer 40

e) CHARGE syndrome - AD genetic disorder, usually no fhx
● Coloboma (hole in structure of eye: iris, retina, choroid disc etc.)
● Heart Defects (including conotruncal like TOF), AV canal defect, aortic arch abnormalities
● Atresia Choanae (unilateral or bilateral)
● Retardation of growth/development (DD, short stature)
● Genital/urinary abnormalities (micropenis, cryptorchidism, hypoplastic labia, delayed puberty)
● Ear abnormalities and deafness (asymmetric, reduced height, cup shaped etc.)
Note major criteria are different than acronym - coloboma, choanal atresia, cranial nerve anomalies, ear anomalies

Question 41

How is CHARGE syndrome diagnosed?

Answer 41

Clinical criteria (all 4 major or 3 major and 3 minor); genetic testing - molecular testing

Question 42

A 3 mo baby with wt. 6.3kg, length normal, hc 47cm. What initial investigation would you do?

Answer 42

Head U/S

Question 43

4 biologic determinants of child development

Answer 43

• genetics
• in utero exposure to teratogens (mercury, alcohol)
• low birth weight
• postnatal illness/ insults (meningitis, TBI, chronic illness)

Question 44

Which of the following interventions would be provided by an Early Childhood Resource
Specialist?
a) Design home or school based activities to practice speech and language skills
b) Provide consultation to parents regarding behavioral concerns and parenting strategies for children with special needs
c) Develop augmentative communications tools
d) Focus on sensory environment to achieve functional daily tasks
e) Provide information on positioning and handling

Answer 44

b) Provide consultation to parents regarding behavioral concerns and parenting strategies for children with special needs

Question 45

You are working in an international adoption clinic. A family brings you a file on a potential adoptee. Which of the following is most likely to correlate with a poor outcome:

a. Microcephaly proportional to height and weight delay
b. Developmental delay proportional to height delay
c. Microcephaly with normal height and weight parameters

Answer 45

c. Microcephaly with normal height and weight parameters - more suggestive to me of underlying syndrome/early exposure that will not be reversible - peds in
review 2004 - preparing families for international adoption (red flags: IUGR, microcephaly out of proportion to other growth parameters, FAS facies)

Question 46

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 46

a . isolated language delay

Question 47

An 18 month old child in your office with the concern of developmental delay. He is babbling but does not yet say mama and dada or any other words. He is able to sit unsupported for a brief period of time. He does not yet have a pincer grasp

a. What is her developmental age?
b. He has a 13 year old brother in “special education” classes and a maternal cousin with autism. What one test would you want to do and why (2 lines)?

Answer 47

A) 6 months
Babbling: 6-8 months
Mama/dada: 9 months
Other words: 12 months
Sit unsupported briefly: 6 months
Pincer grasp: 9 months

B) fragile X - male child with global delay, has a brother similarly affected and fragile X is X-linked and would come from mother - notable that there is another affected relative on mom’s side; fragile X can present like autism

Question 48

A 3 y/o girl with regression of milestones is noted to have microcephaly. What is the most likely diagnosis:

1. Childhood disintegrative disorder
2. Autism
3. Rett’s
4. Fragile X
5. TORCH infection

Answer 48

3. Rett’s
4. Childhood disintegrative disorder - removed from DSM 5, not associated with microcephaly; now part of autism spectrum disorder
5. Fragile X - accounts for 3% of males with intellectual disability, females have less severe disease, no regression

Question 49

You are seeing a 2 year old girl in whom you have told the family that you are suspicious of autism. The mother has been doing some research and asks you questions about Rett syndrome. Name 4 features of Rett Syndrome.

Answer 49

• gait ataxia
• impaired language skills
• seizures
• regression of previously acquired milestones
• acquired microcephaly
• loss of purposeful hand movements + hand wringing
• sighing respirations
• normal prenatal/perinatal course
• normal development until at least 6 months

Question 50

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 50

c. Mom did not finish high school

Question 51

Mother used IV heroin before and during her pregnancy. Her 10 month old child is now losing acquired milestones and developing bilateral spasticity. The most likely cause is:

a. HIV
b. CMV
c. cerebral palsy
d. syphilis

Answer 51

a. HIV
CNS HIV: variable - mild developmental delay to progressive encephalopathy with loss
or plateau of milestones, cognitive deterioration, impaired brain growth leading to acquired
microcephaly and symmetric motor dysfunction
- spasticity, hyperreflexia and gait disturbance can occur

Re: syphilis: babies with congenital neurosyphilis may have seizures, but otherwise wouldn’t present this way

Question 52

You are seeing a 9 month old in your office. She is babbling and understands the command “no”.
She cries when you take her away from her mother. She rolls but does not sit. She picks up a small
object with an immature pincer grasp. What do you say to her mother about her development?
a) Her development is normal
b) She has delays in her language skills
c) She has delays in her social skills
d) She has delays in her gross motor skills
e) She has delays in her fine motor skills

Answer 52

d) She has delays in her gross motor skills

Question 53

A 4 year old comes to your office with the concern of developmental delay. He can say his full
name, age, and sex, as well as count to 3 and name 3 body parts. He can ride a trike and stand
briefly on one foot. He helps to undress himself and plays pretend games with other children. He can
copy a circle and a cross. What is his developmental age:
a. 24 months
b. 36 months
c. 48 months
d. 60 months

Answer 53

b. 36 months

Question 54

Developmental concerns associated with neonatal risk factors, motor delays, genetic conditions are typically identified early, often by primary physicians. Milder, often very common, developmental concerns are often not identified until later in childhood or upon school entry. Which of the following conditions is more likely to be identified in a school aged child rather than a younger child?

a) Learning disability
b) Mild cognitive issues (mild MR, borderline cognitive abilities)
c) Aspergers syndrome
d) 1 and 3
e) All of the above

Answer 54

e) All of the above

Question 55

You are seeing a 10 year old boy with a previous diagnosis of MR. He is not dysmorphic and his growth parameters are at the 50 th percentile. He functions like a 5-6 year old. He did have a genetic work up which as all normal. His mother wonders if the cord wrapped around his neck at birth was the cause of his cognitive impairments. He needed minimal resuscitation. What do you say to her?

a) An etiology is commonly found for children with MR
b) He needs more testing to answer her question
c) He should have an MRI to delineate the etiology of the MR
d) It is unlikely that the delivery was the cause of his cognitive impairments
e) His diagnosis needs to be reviewed

Answer 55

d) It is unlikely that the delivery was the cause of his cognitive impairments

o Mild: IQ 50-70= mental age as adult near 9-11 y.o.
▪ more environmental; identifiable cause in < 50%
▪ If biocause: genetic or chromosomal (Williams, Noonans), IUGR, prem,
prenatal exposure (FAS)
o Severe: IQ < 50= mental age as adult near 3-5 y.o.
▪ identified cause in > 75%
▪ Chromosomal: T21, Wolf-Hirschhorn Syndrome
▪ Genetic and Other: Fragile X, Rett Syndrome, Angelman, Prader-Willi
▪ Abnormal brain: example lissencephaly
▪ Inborn errors of metabolism or other neurodegenerative

Question 56

Which of the following is a sign of Aspergers:

1. Gross motor delay
2. Preserved language development
3. Adequate social skills
4. Fine motor delay

Answer 56

2. Preserved language development

Question 57

You are asked to assess a child for autism. Which of the following statements would best support the diagnosis?

a) child takes toys from other children in the examining room
b) child consistently displays a startle response to a ringing telephone
c) child spends much of the examination spinning a wheel on a toy truck
d) child brings each of the toys into the exam room to show his mother

Answer 57

c) child spends much of the examination spinning a wheel on a toy truck

Autism diagnosis: persistent impairment in social communication and
interaction + restricted repetitive pattern of behavior/interest

Question 58

What are the 2 core criteria of autism diagnosis and an example of each?

Answer 58

1. impairment in social communication and interaction
   - deficits in developing/maintaining relationships; deficits in non verbal behaviours; deficits in socio-emotional reciprocity
2. restrictive, repetitive behaviours or interests
   - stereotypies (echolalia, hand flapping, spinning)
   - inflexibility/strict demand for routine
   - restricted fixated interests
   - hyper/hyporeactivity to sensory inputs

Question 59

A mother has a 2 year old child recently diagnosed with autism. Mother is currently pregnant with her second child and wants to know the risk of this child also having autism. What do you tell her about the recurrence risk?

a. It is lowered if she does not give the MMR vaccine
b. There is no difference from the population risk
c. There is a slightly increased risk over the general population

Answer 59

c. There is a slightly increased risk over the general population

● RF: male
o FHX: high recurrence risk in siblings (2-19%)
o Closer spacing of pregnancies
o Advanced maternal or paternal age
o Extreme prem birth (< 26 wk GA)
o FHX (+) for LD, psychiatric dx or social disability

Question 60

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
d. Preserved language development

Answer 60

c. Does not point to things to show interest

Question 61

3 year old male talking at a 1.5 year level. No echolalia. Plays normally. Comprehension better than expression. Motor development normal. What is he at risk for

a. PDD
b. Developmental Disorder

Answer 61

b. Developmental Disorder (abnormal pattern of development) - seems at risk for language disorder

(PDD = autism)

Question 62

A 4 yo child with symptoms of autism. What is the diagnosis (1). What 2 neurologic disorders are associated with this.

Answer 62

1) Autism

2) Tuberous Sclerosis and Neurofibromatosis (Angleman, Rett, Fragile X)

Question 63

Description of a child with florid autism. Name 3 tests you should order. Which 2 consultants or services would you involve to help you with your diagnosis?

Answer 63

1 ) Hearing Test, Microarray, Fragile X

2) Developmental Pediatrician, Speech and Language Therapist

Question 64

List 4 diagnostic features of autism.

Answer 64

• Impairment in social communication and social interaction
• Restrictive and repetitive behaviours/ interests
• Presence in early developmental period
• Significant impairment in social occupational or other area of functioning

Question 65

A mother brings her 1-year-old child for concern regarding head banging. Physical exam is normal. The parents are worried about brain damage. What should you do:

a) reassure
b) EEG
c) CT head
d) use a helmet to prevent head injury
e) family psychological assessment

Answer 65

a) reassure
- typically begin in the 3 years of life, often before age 2 years
- in typically developing children the movements resolve over time
- specifically self-injurious behaviours like head banging occur in up to 25% of toddlers but in kids over 5 are almost always associated with developmental disorders
- Developmentally Normal child unlikley to hurt themselves from injury

Question 66

Parents bring their 18 month old son to see you because of concern about head banging. What treatment, if any, do you offer (1)?

Answer 66

Reassure- cannot cause brain/skull injury (in normally developing children) and usually grow out of it
▪ Mild- ignore the behavior, encourage substitute behavior and do not convey worry to child
● May disappear with time and elimination of attention

Question 67

Mom has son with aggressive behaviors. You want to start risperidol. What 3 SERIOUS side affects will you tell mom about drug

Answer 67

Extrapyramidal symptoms
	Hyperprolactinemia
	NMS
	Tardive Dyskinesia
        Dyslipidemia
	Type 2 DM
	Sedation

Question 68

Child 3 y/o referred for behaviour problems. Mom concerned because child refuses to wear patch for amblyopia for the past 8 months. What do you do?

1. Refer to social work
2. Immediate referral to ophthalmology for other treatment modalities
3. Refer to ophthalmology once child has started to wear patch again
4. Refer to parenting class through public health to learn skills to make child wear patch

Answer 68

2. Immediate referral to ophthalmology for other treatment modalities

Question 69

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

Answer 69

b. request a meeting with both parents to assess the home situation.

Question 70

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 70

c. best if parents can settle their differences and not fight in front of kids

Question 71

10 year old boy who has recently been made aware that his teenage brother is dying of ALL. He spends all his time out with his friends and is not wanting to be with the family. Mother concerned - what do you tell her?

Answer 71

• Death of family member is most difficult loss for a child
• Reluctant to talk because adults around them are uncomfortable to talk
• Turn to peers and tell adults they don’t want or need to talk about it
• Presence of secure and stable adults to meet needs and permit discussion about the loss is
  most important
  o No single way to grieve- respect difference and reach out to support each other
  o Maintain emotional/ physical presence (hug, talk, ask)

Question 72

A 13 y/o boy starts fires, school problems, hurts pets, threatened a child at school with a knife.
What is his likely diagnosis?
1. ODD
2. Conduct Disorder
3. ADHD

Answer 72

2. Conduct Disorder

Question 73

9 year old boy who has killed a cat in the last year and set fires to property. He has also been caught stealing and is aggressive at school. What is his diagnosis?

a. oppositional defiant disorder
b. conduct disorder
c. ADHD
d. Antisocial personality disorder

Answer 73

b. conduct disorder

Question 74

You see a 7 year old child with the concern of thumb-sucking. Which of the following is important
to include in the discussion of the risks and benefits of intervention in this patient:
a) Thumb-sucking never causes self-esteem issues
b) Thumb-sucking can lead to dental malocclusion and facial growth abnormalities
c) Topical deterrents are very effective

Answer 74

b) Thumb-sucking can lead to dental malocclusion and facial growth abnormalities
- thumb sucking beyond 5 years can be associated with paronychia (red, tender bacterial or fungal infection at base of nail) and anterior open bite (gap between upper and lower front teeth)

Question 75

A 4 yo sucks her thumb while watching TV. What to tell mom?

a. Put a bitter tasting substance on her thumbs
b. Reassure
c. Prescribe a mouth appliance
d. Reward system

Answer 75

d. Reward system

25% of 2 year olds, 15% of 5 year olds. Beyond 5 a/w sequelae

• mgmt: ignore thumb sucking; praise child for alternate behaviours
• reminders and reinforcement (sticker for each block of time with no thumb sucking)

Question 76

A 30 month old child with temper tantrums starting after the onset of attempting toilet training. What to do:

1. Time outs
2. Persevere
3. Take a 1-3 month break from toilet training
4. Reward with stickers each time on the potty

Answer 76

3. Take a 1-3 month break from toilet training

Question 77

2 yo with temper tantrums. Give advice to mom x2

Answer 77

• tantrums are common in this age group, triggered by anger/feeling overwhelmed and more likely if child is tired or hungry
• put in time out at early signs of tantrum to prevent escalation
• ***positive reinforcement for times when they are tantrum free
• redirect to another activity
• set limits and routines and have realistic expectations

Question 78

20 month old child. Each time the parents say “no” child cries, turns blue and then passes out with some generalized tonic clonic movements. He recovers within 1 minute and the parents administer CPR. What do you recommend?

1. Consistent discipline
2. do not upset the child

Answer 78

1. Consistent discipline

Breath holding spells - common in 6-18 months, can occur until age 5
● Tx: try to intercede before child highly distressed (time out, parent model anger control
you want child to show)
● Tx: ignore behavior when start

Question 79

An 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 79

a) this should improve if she learns to fall asleep in her crib vs. being rocked to sleep

Question 80

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 80

c. 11-13 months (most should be able to by ~12 months)

Question 81

You are referred a 15 year old boy with a history of fatigue. On history you find that he is going to bed very late and having to get up very early for school each morning. There is nothing else concerning on history. What are five recommendations you make to him and mother regarding sleep hygiene?

Answer 81

• Set bedtime/wake-up, similar on weekends
• Regular routine
• Quiet and comfortable sleep environment - dim lights, calm environment
• Don’t go to bed hungry, light snack.
• Avoid heavy meal within 1-2 hr before bed
• Avoid stimulation (Tv, computers, video games within 1-2 hours of bed time)
• avoid caffeine after mid-afternoon
• no smoking, alcohol, herbal remedies for sleep
• Read a book (not tablet) to mentally fatigue
• Increase physical activity in daytime (but not within two hours of bedtime), spend time outside
• Limit bed use to sleep (not for tv, eating, homework)
• do not use room for time-out or punishment

Question 82

A father comes to you because his 4 year old child has been awakening every night for the past 2 months; he and the child’s stepmother have gotten only 1 night of sleep per week over this time period. The child wakes every night at midnight and cries inconsolably for a short time before going back to sleep. She does not remember it in the morning. What do you advise:

a. Wake her every night at 11:45pm for 10 minutes for 7 days
b. No naps at day care
c. No liquids two hours prior to bedtime

Answer 82

a. Wake her every night at 11:45pm for 10 minutes for 7 days - actually need to do it for 4 weeks to see improvements
- only intervene to stop them from hurting themselves

(child has night terrors)

Question 83

Description of night terrors. List two things to do for management.

Answer 83

• education and reassurance (self-limited)
  -avoid sleep restriction and caffeine
  (which both increase Slow Wave Sleep)
  -scheduled awakenings 15-30 min prior to expected episode if occurring nightly - need to do this for 2-4 weeks

Question 84

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 communicate need for toilet using full sentences

Answer 84

b. desire to please based on positive relationship parents

Question 85

An 8-year-old with primary nocturnal enuresis has tried the alarm for 8 weeks without success. He wants to go to summer camp. The best option is:

a) DDAVP
b) amitriptyline
c) imipramine at bedtime
d) imipramine 25 mg tid

Answer 85

a) DDAVP

Desmopressin (synthetic ADH) work short term and best
for camps and sleepovers. Avoid fluids 1hr before and 8h after
- note: imipramine is a TCA and can be used at bedtime (takes one week to reach effect); DDAVP better option

Question 86

What would you suggest for a 7-year-old boy with nocturnal enuresis who sleeps through the night:

a) DDAVP
b) imipramine
c) conditioning alarm
d) parent awakening program

Answer 86

c) conditioning alarm

50% cure rate long term, but most effective treatment we have; needs motivation of child and whole family; can also just wait it out and not do anything

Question 87

Mother comes to see you about starting to toilet train her child. What 5 questions can you ask her to assess for readiness.

Answer 87

o Gross Motor
▪ Able to walk to the potty chair (or adapted toilet seat)
▪ Stable while sitting on the potty (or adapted toilet seat)
o Control
▪ Able to remain dry for several hours
o Language
▪ Receptive language skills allow the child to follow simple (one and two step) commands
▪ Expressive language skills permit the child to communicate the need to use the potty (or adapted toilet seat) with words or reproducible gestures
o Social
▪ Desire to please based on positive relationship with caregivers
▪ Desire for independence , and control of bladder and bowel function

Question 88

4 year old with primary enuresis. What is one important piece of advice that you should give to the parents?

Answer 88

This is still within a normal range to not yet be dry; avoid battles over toilet and provide encouragement and praise any successes; no punishment or humiliation

Question 89

All of the following are features of sleepwalking EXCEPT:

a) occurs during stage 4 non-REM sleep
b) positive family history
c) can walk around furniture
d) do not walk into dangerous areas
e) resolve spontaneously in later childhood

Answer 89

d) do not walk into dangerous areas

Question 90

2 year girl who has episodes of abnormal breathing and movements. Occurs when watching TV or bored. Mum can decrease length of episodes when talking to her. Episodes last 5-6 min. She seems responsive throughout the episodes. What do you recommend to do to mum (1)?

Answer 90

Reassure - infantile masturbation

Question 91

A child who is described as having a learning disability, has big ears. Mom has an LD as well. What to tell mom to expect:

1. Problems with tics
2. Problems with athetosis
3. Problems with hyperactivity
4. Problems with tremor
5. Problems with nystagmus

Answer 91

3. Problems with hyperactivity

Fragile X associated with hyperactivity (80% have ADHD)

Question 92

An 8 year old boy at risk for failure in school is sent to your office for evaluation for specific learning disorders. History and physical exam are within normal limits. Which of the following do you do next:

a. Trial of stimulant medication
b. Psychological assessment
c. CBC, TSH and Pb level

Answer 92

b. Psychological assessment

Specific LD - most common is reading disorder (dyslexia) - 80% of kids with LD
- NO Ix beyond history, physical and psychometric testing needed

Question 93

A 10 year old boy with a history of myelomeningocele and VP shunt placement for hydrocephalus comes to your office with a history of a recent decline in school performance of several months duration. There are no specific neurological, urological or MSK complaints and he does not complain of any pain. A CT scan is done and does not show any change from previous. Which of the following is your next step in management:

a. EEG
b. Psychological assessment
c. Assessment by neurosurgery
d. Trial of stimulant medication

Answer 93

a. EEG - due to short duration
b. Psychological assessment

70% have normal intelligence but learning problems and seizure disorders are more common than the general population
Seems a little short to be an LD

Question 94

3 yo with isolated language delay. What do you tell mom he is at risk for?

a. Reading disability
b. ADHD
c. Articulation disorder.

Answer 94

a. Reading disability (dyslexia)

Question 95

2. 5 year old child. Which is most consistent with an expressive language disorder?
   a. 100 word vocabulary
   b. no pronouns
   c. no 2-word combos
   d. stuttering

Answer 95

c. no 2-word combos

Question 96

17. Child with dysfluency. List four indications to refer to speech therapy.

Answer 96

Dysfluency = stuttering

• Preschool or older
• 3 or more dysfluencies per 100 syllables
• avoidances or escapes (pauses, head nod, blinking)
• discomfort or anxiety while speaking
• suspicion of associated neurologic or psychotic disorder

Question 97

What is the best predictor of difficulty reading in JK?

Answer 97

• Language disorder

o Strongly related to later reading disorder

Question 98

Teacher concerned about 4 yr old child who can’t use scissors, can’t copy a square… she wonders about developmental coordination disorder. List 2 diagnostic criteria for developmental coordination disorder.

Answer 98

A) Acquisition/ execution of coordinated motor skills below expected (clumsiness, slowness, inaccuracy of skill)
a. Examples: catching, using scissors/cutlery, handwriting, riding a bike, sports
B) Significantly/ persistently impairs activities of daily living (self-care and self-maintenance) and school productivity, activities, play
C) Onset in early developmental period
D) Not better explained by ID, visual impairment or neurological condition

Question 99

A 6-year-old boy has been having involuntary tics for approximately 1 month. He is in grade 1 and doing well. His mother feels that their onset correlates with the death of his grandfather.

You suggest:

a) wait
b) refer to psychiatrist
c) treatment with haloperidol
d) treatment with methylphenidate
e) tell his mother that he will have Tourette’s syndrome

Answer 99

a) wait

• treat tics only if interfering with function and are a problem for the CHILD
• need at least 1 year of symptoms for tourette

Question 100

You are about to put a child on stimulant medication for his ADHD. The mother asks you about the potential for increasing his potential for future drug addiction.

What do you counsel her about her son’s future risk:

a. Stimulants have no effect on risk of drug addiction
b. Stimulants decrease future risk of drug addiction
c. There is an increased risk of drug addiction, but less so with the dextroamphetamines

Answer 100

There is evidence to support:
b. Stimulants decrease future risk of drug addiction

But as per the newest evidence:
a. Stimulants have no effect on risk of drug addiction

Question 101

Mother brings in her child who has a diagnosis of ADHD, you are treating him with long-acting Ritalin. What is a late onset side effect of stimulants:

a. Decreased appetite
b. Difficulty sleep
c. Tics
d. Depression

Answer 101

d. Depression

Height would actually be a better answer

Question 102

What is true about methylphenidate:

a) stimulates appetite
b) no effect on growth velocity
c) may exacerbate tics
d) can cause dependency
e) effective in 60% of children with ADD

Answer 102

ANSWER: c) may exacerbate tics

Effect size is about 75%

Question 103

A 6 yo boy in grade 1 is not paying attention, disruptive, in danger of failing. He does not read or write as well as his classmates. Appropriate action:

a) fail him
b) full psychoeducational assessment
c) Ritalin
d) classic slow learner

Answer 103

b) full psychoeducational assessment

Question 104

Which is true of ADHD?

1. teacher and parent reporting of symptoms on a checklist frequently agree
2. check for lead poisoning in each kid with ADHD
3. 25% of kids with ADHD have comorbid anxiety disorder
4. kids with ADHD often have thyroid hormone abnormalities

Answer 104

3. 25% of kids with ADHD have comorbid anxiety disorder

Question 105

Which of the following medications used to treat ADHD is not a stimulant?

a) Concerta
b) Dexadrin Spansules
c) Biphentin
d) Strattera
e) Ritalin SR

Answer 105

d) Strattera (NON STIMULANT= Second line Non stimulant Agent= generic name Atomoxetine - SNRI) - good if comorbid anxiety disorder

a) Concerta (Methylphenidate group= Ritalin, Biphentin, Concerta)
b) Dexadrin Spansules (Dextroamphetamine Group= Dexedrine, Adderall, Vyvanse)
c) Biphentin (see above)
e) Ritalin SR (Yes Methylphenidate group)

Question 106

An 8 year old boy with his father is seen for school concerns. There have been concerns raised by his teacher that he is not getting his schoolwork done. He needs reminders to do his work constantly. He is often chatting in class and often out of his seat. His medical history is unremarkable. His hearing is normal. His parents report similar concerns doing homework. What would be your initial course of action?

a) Trial of stimulant medication
b) Behavioural management referral
c) Family counseling
d) Psychiatric referral
e) Evaluation of academic skills

Answer 106

a) Trial of stimulant medication

If kid under 6, trial behavioural strategies first

Question 107

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?

a. start Straterra
b. Consult a psychiatrist
c. Change from 7 days a week dosing to 5-days a week.

Answer 107

c. Change from 7 days a week dosing to 5-days a week.

Question 108

Name 3 DSM-V diagnostic criteria for ADHD - inattentive subtype.

Answer 108

• lacks attention to detail/careless mistakes
• cannot sustain attention
• does not listen when spoken to directly (mind wandering)
• does not follow through (starts but does not complete chores, homework)
• poor organization/time mgmt
• avoids tasks requiring sustained mental effort
• loses important things
• easily distracted
• forgetful about daily activities

Question 109

Name 3 DSM-V diagnostic criteria for ADHD hyperactive/impulsive subtype.

Answer 109

• fidgets/taps hands/squirms
• leaves seat inappropriately
• runs or climbs inappropriately
• unable to play quietly
• is “on the go”
• talks excessively
• blurts out answers, completes peoples’ sentences
• cannot wait turn (e.g. in line)
• interrupts or intrudes on others

Question 110

How many criteria are needed for a diagnosis of ADHD mixed sub-type.

Answer 110

meet diagnostic criteria for both inattentive AND hyperactive subtype (6/9 for both - i.e. have minimum 12 symptoms)

Question 111

Describe a child having difficulty in school. Teacher complains child not listening in class. Not getting homework done. List 3 things on your differential diagnosis.

Answer 111

• Hearing impairment
• Vision impairment
• earning disability
• ADHD

Question 112

Kid with known separation anxiety. Management of school phobia?

a. Return to school immediately
b. Return gradually with parents leaving gradually
c. Give SSRI
d. Give benzo

Answer 112

b. return gradually with parents leaving gradually
or
c. Give SSRI

Depends on the severity. Would recommend parent training - send kid to school calmly and reward to days spent at school. If severe and persistent then consider SSRI + CBT. Make sure you’re treating the child and refer the parent if there is suspicion of AD/Depression

Question 113

A 10 yo boy has headache, abdominal pain and lethargy anytime of the day . He has missed 30 days of school in 4 months. He has:

a) migraines
b) school phobia
c) Brain tumour

Answer 113

b) school phobia

Question 114

3 mos girl BW SGA at 2200g at GA38, now wt 10th, ht 25th, HC 50 th

1. 2 yr for catch up growth in IUGR
2. f/u in 6 mos no nutritional intervention
3. need w/u for organic FTT
4. increase dietary protein
5. if not at 50th %ile by 6 months then needs work up for organic FTT

Answer 114

1. 2 yr for catch up growth in IUGR

Question 115

A 3 year old child comes to your office with concerns of failure to thrive. He is impulsive and destructive in your office and hugs you repeatedly on his first visit. He only says 8 words and does not form 2 word sentences. His mother states that he has a voracious appetite. What is his
diagnosis:
a. psychosocial deprivation
b. attention deficit disorder
c. diencephalic syndrome

Answer 115

a. psychosocial deprivation

Question 116

Child with severe trigonocephaly. What is your management?

1. sablage of metopic suture
2. helmet
3. place child face down
4. craniostomy with removal of metopic suture

Answer 116

4. craniostomy with removal of metopic suture

- if very mild, no treatment needed

Question 117

A child has sustained a head injury and has been intubated in ICU with a fluctuating GCS of 6-9 for several days. There is no evidence of intracranial bleeding or cerebral edema. Upon discharge, the mother can expect her child to develop:

a) fine motor problems
b) seizures
c) insomnia
d) behavior problems
e) psychiatric problems

Answer 117

d) behavior problems

• cognition is most affected following TBI
• also develop behavioural issues, and problems with learning, memory

Question 118

Sign of sexual abuse?

a. Midline anal tag
b. Scar outside of midline anus
c. Atrophic shiny vaginal mucosa
d. Big rectum > 2 cm with lots of stool

Answer 118

b. Scar outside of midline anus (suggestive of abuse per AAP paper on signs of sexual abuse)

NOTE: c. Atrophic shiny vaginal mucosa - normal description of vaginal mucosa prior to exposure
to estrogen

Question 119

A 9 year old is seen in your office with symptoms of depression and suicidal ideation. Which of the following is a risk factor for this presentation:

a. Bullying
b. Recent parental divorce
c. Impulsive behaviour
d. Poverty

Answer 119

a. Bullying (likely most correct given CPS and Nelson’s)

recent divorce is also a risk factor, but if divorce leads to resolution of frequent conflict can actually be a relief for kids

Question 120

An 8 year old child is slow to write because he checks each letter 3 times as he writes it. He has no trouble in his interpersonal relationships. What is the diagnosis:

d. Normal behaviour
e. OCD
f. ADHD

Answer 120

e. OCD

Question 121

An 11 year old girl with a maternal history of bipolar disorder has recently become irritable and restless. She is only sleeping 5 hours per night.

What is her most likely diagnosis:

g. New onset of ADHD
h. Bipolar disorder
i. Marijuana abuse

Answer 121

h. Bipolar disorder
(although it’s not very clear - at this point doesn’t actually meet criteria)

BPD is very heritable

Question 122

The following is true of post traumatic stress disorder

a. Intrusive memories
b. Vegetative symptoms
c. No emotional disturbances prior event

Answer 122

a. Intrusive memories

Question 123

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 123

b) reassure parents that this is normal separation anxiety appropriate for child’s developmental level

18-24 months

• increased clinginess around 18 months
• parents feel they “can’t go anywhere” without a kid hanging off them
• separation anxiety often manifests at bedtime
• many children use a special blanket or stuffed toy as a transitional object

Question 124

Question on car seat indications. When can the child use regular seat belt?

a) When child weighs 41 lbs
b) If child is > 6 yrs old
c) when child, while in booster seat, has level of ears over headrest of the seat
d) when child has a sitting height at or greater than 63 cm

Answer 124

c) when child, while in booster seat, has level of ears over headrest of the seat

CPS Guidelines- At least 36kg 145cm or 9 years old

Question 125

You are treating a child, and you have a suspicion of Munchausen by Proxy disorder ( now falls under category of factitious disorder imposed on another in DSM V) . 
Define MBPD (1 line). 
Name 3 features that are characteristic of MBPD.

Answer 125

1. Form of maltreatment in which parent simulates or causes disease in their child
   o Reported symptoms only by one parent
   o Testing fails to identify medical diagnosis
   o Appropriate treatment ineffective
   - diagnosis does not match objective findings
   - signs/symptoms are bizarre
   - caregiver does not express relief when told child is improving
   - inconsistent histories
   - caregiver insists on painful/invasive procedures
   - sibling with unusual or unexplained illness/death
   - failure of child to respond to normal Tx or unusual intolerance

Question 126

A child shows features of Obsessive-Compulsive disorder. Define obsession and give 1 example (2 lines). Define compulsion and give 1 example (2 lines).

Answer 126

1. Obsessions: recurrent and persistent thoughts, urges or images that are intrusive and unwanted and cause distress
   - e.g. bodily wastes and secretions, fear of something calamitous, fear of contamination
2. Compulsions: repetitive behaviours or mental acts performed in response to an obsession according to rigid rules. Acts are aimed at reducing anxiety but are not logically connected to the obsession they are neutralizing
   - e.g. hand washing, checking of locks, washing and cleaning

Question 127

What criteria is a necessity for the diagnosis of OCD to be made (1 line)?

Answer 127

Presence of obsessions, compulsions or both that are time consuming, distressing and unwanted

Question 128

An 8 month old baby who 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. Falling asleep in crib vs mom’s arms will be preventative
b. Letting baby cry will eliminate the problem
c. Giving the baby a pacifier is a proven technique
d. Give a bottle of warm milk while in bed

Answer 128

a. Falling asleep in crib vs mom’s arms will be preventative

Question 129

Pt treated with prozac for 2 years. What is the chance of recurrence of depression once she is taken off this medication.

1. 10%
2. 20%
3. 40%
4. 75%
5. 90%

Answer 129

40%

Treat for 6-12 months. Slow taper off.

Question 130

6 y/o boy with 2 weeks of sudden onset of OCD behaviours. Which infectious agent would you be concerned about: Repeat

1. Strep pneumonia
2. Group A Strep
3. E. Coli
4. H. Flu
5. Echovirus

Answer 130

2. Group A Strep

Question 131

A mother is concerned that her thirteen year old boy has recently started spending more time in his room, he is more tired and has difficulty awaking in the morning. He doesn’t participate in sports, and spends all of his time on his computer or with his friends. He is doing just below the average in school. When you speak to him, he says he smokes occasionally but denies any other alcohol or drug use. What do you do next:

a. Psychological assessment
b. Trial of stimulant medication
c. Reassure

Answer 131

a. Psychological assessment

Should screen for mood disorders

Question 132

A teenage boy admits to having violent thoughts that overwhelm him. He says the thoughts are frequent and that he has not hurt anyone yet but fears he will soon. What diagnosis is most likely?

1. Behavioural problem
2. OCD
3. Schizophrenia
4. Antisocial personality

Answer 132

2. OCD

Question 133

10 yo female with long history of handwashing 10-12 times per day. Now handwashing 100 times per day. She also has new onset eye blinking and throat clearing. She had a sore throat 2 weeks ago. What should she be treated with?

a) Risperadol
b) Clonidine
c) Penicillin
d) Dexedrine

Answer 133

c) Penicillin

PANDAS

Question 134

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 134

d) Dyslexia (specific LD in written expression)

Question 135

7 year old girl whom you have seen before for her asthma. Has missed 1 month of school because in the morning she complains of feeling “tight”. Later in the day feels fine and is not missing other extracurricular activities. What is the likely cause?

a) Anxiety Disorder
b) Depression
c) Status asthmaticus

Answer 135

a) Anxiety Disorder

Question 136

11 year old boy who has had recent personality changes, decline in school performance and visual changes. Which is the first diagnosis to rule out:

d. Brain tumour
e. DM
f. ADHD

Answer 136

d. brain tumour

Question 137

15 year old girl with frequent brief attacks where she feels short of breath and vaguely uneasy. Which of the following would support your diagnosis:

g. Fear of episodes recurring and sudden onset of episodes
h. Family history of OCD
i. History of emotional trauma

Answer 137

g. Fear of episodes recurring and sudden onset of episodes

Question 138

Young girl who complains of chest tightness in the morning. Improves throughout the day. Does not interfere with activities.

She has missed a lot of school in the past two months. What is her diagnosis?

a) separation anxiety
b) generalized anxiety
c) status asthmaticus

Answer 138

a) Separation anxiety

Begins at 10 mo, tapers by 18mos. By 3years most can accept temporary absence of primary caregiver

Question 139

Trichotillomania
A – is associated with OCD in older kids
B – is usually self-limiting
C – is rare

Answer 139

A - is associated with OCD in older kids

Question 140

Most concerning at 14 mths development

A. Not pointing out of interest
B. no single words
C. Not understanding 2 step commands

Answer 140

A. Not pointing out of interest (should be doing this by 12 months)

Question 141

5 yr old with normal speech. Stuttering, what would you be most concerned about

A. facial tension
B. pausing between words
C. repeating parts of words
D. repeating whole words

Answer 141

A. facial tension

Question 142

Sign of ready for toilet training
A. Desire to please
B. Follow 2 step command
C. Speak in full sentences

Answer 142

A. Desire to please

Checklist:

• walks to potty
• stable sitting on potty
• remain dry for several hours
• follows simple 1 and 2 step commands
• can communicate need to use potty
• desire to please
• desire for independence

Question 143

When can an infant self-soothe?
A. 3-5 mths
B. 5-7 mo
C. 7-9 mths
D. 9-11 mths

Answer 143

A. 3-5 months

Question 144

112. What is most concerning in a 5mth old

A. fisting of right hand
B. not always smiling at caregivers
C. Only sitting with pelvis supported
D. not consistently turning to name

Answer 144

A. fisting of right hand

Worrisome for CP after 2 mos

Question 145

Kid with aggressive outbursts and language profanity, now kicked out of school. What medication would you prescribe, along with Ariprazole (Abilify).
A. Clonidine
B. Methylphenidate

Answer 145

B. Methylphenidate

Management of ODD and CD: medications include stimulants and atypical antipsychotics.

Question 146

6 yo referred to clinic with ADHD symptoms. In last months, his mother notes inc difficulties in school and at home. He is less receptive in class. Your exam is unremarkable despite slightly ple optic discs bilaterally. He also has progressive visual and hearing loss. You diagnose

A. ADHD
B. A glycogen storage disease
C. Adrenoleukodystrophy
D. A normal child

Answer 146

C. Adrenoleukodystrophy

Adrenoleukodystrophy (Nelson’s) :

• disorder of very long chain fatty acids
• genetically determined - X-linked
• Childhood cerebral form: symptoms of hyperactivity mistaken for ADHD at age 4-8yo → worsening performance in school; can also have impaired auditory discrimination, spatial orientation, vision impairment, ataxia, poor handwriting, seizures, strabismus.

Question 147

9 yo girl whose parents divorce. What is her likely reaction?

A. Blame herself
B. Believes they will get back together
C. pick sides
D. feels excessive responsibility for her parents well-being

Answer 147

C. pick sides

Younger kids - blame self (magical thinking) - dr D have put this as her answer

Question 148

Toddler with “description of breath-holding spells”.

What treatment, if any, would you recommend to mom?

Answer 148

• Treatment of iron deficiency
• Education : calm child before episodes ramp up
• Reassurance - self limited and will outgrow within a few years
• Do not provide secondary Gian for child

Question 149

7 year old male with difficulties leaving mother, along with refusal to go to school. What treatment would you advise?

a) CBT
b) Benzo PRN
c) Antipsychotic
d) Family therapy

Answer 149

a) CBT
(but FYI - we don’t typically start until 8 years)

± SSRI

Question 150

4mo old with eruption of 2 new teeth, what do you do?

a) Brush with water only
b) Brush with fluoride toothpaste
c) Send to dentist now and every 6 months
d) Discontinue night time feed

Answer 150

A) Water only

Start fluoride at 3 years (when they can spit), send to dentist 6 months after first tooth or at 12 months

Question 151

A 10 year old boy with ADHD and is stable on stimulants for 2 years. He presents with increased aggressive behavior and difficulty following limits. His sleep and appetite are otherwise normal. After ruling out psychological stressors. Which of the following is the most appropriate action:

1- Increase his stimulant dose
2- Use benzo PRN
3- Add atypical antipsychotic
4- Add an SSRI

Answer 151

1 - increase stimulant dose

You can get tachyphylaxis. If dose is optimized you can consider Atypical antipsychotic

Question 152

8yo boy with 1 year of worsening tics including blinking, lip smacking, tugging at his ears, clearing throat, other vocal tics. Very distressed by this and teased by kids at school. What do you do?

a) Reassure and follow up in 6 months
b) Refer for psychological assessment
c) Start alpha 2 agonist
d) Start a benzodiazepine

Answer 152

c) Start alpha 2 agonist

Meets the Tourette’s criteria
Can start Intuniv, especially effective if have co-morbid ADHD

Question 153

School aged child, difficulty making friends, doesn’t get invited to birthday parties. Doing well academically. Has a very organized desk and gets upset with people when they touch it. Does not make eye contact with classmates.
1- OCD
2 - ASD
3- Social anxiety

Answer 153

2. ASD

Question 154

An 11 year old boy has been calling his mother very frequently to see if she’s alright because he worries that something terrible is going to happen to her. He does not want to go to school because he worries about leaving her. En route to school, he never steps on the cracks and when a green car passes, he needs to take an alternate route. What do you use to treat?

a) Benzodiazepine
b) Family therapy
c) Fluoxetine
d) Gradual exposure therapy

Answer 154

c) Fluoxetine or
d) gradual exposure therapy

Sounds like OCD (with a flavour of separation anxiety)

The best treatment course for OCD is exposure therapy and SSRI.

Question 155

What is the best way to prevent people with disabilities from suffering sexual abuse.

a) Less autonomy
b) Putting them in day facilities with more supervision
c) Better sexual education

Answer 155

c) Better sexual education

Question 156

8 year old anxious kid. No issues with body image or fear of gaining weight. He has become more selective with his eating and now only eats chocolate pudding. His weight has decreased from 50th%ile to 10th%il.e. What is the diagnosis?

a) Picky eater
b) ARFID
c) Anorexia nervosa
d) Bulimia

Answer 156

b) ARFID

The eating behavior leads to a persistent failure to meet nutritional and/or energy needs, manifested by at least one of the following:

• Clinically significant weight loss, or in children, poor growth or failure to achieve expected weight gain
• Nutritional deficiency
• Supplementary enteral feeding or oral nutritional supplements are required to provide adequate intake
• Impaired psychosocial functioning

Question 157

12 yo boy breaking things at home, not listening to instructions, and skipping school. He seems angry. What is the next BEST step?

a) Parent training
b) Start an atypical anti-psychotic
c) Start an SSRI

Answer 157

a) Parent training

Screen for ADHD

Question 158

Mother of a 3 yo girl is concerned about her speech. She said her first words at 11 months. There are no concerns with development. She has had difficult speaking: will repeat the same word (mommy, mommy, mommy) and repeat sounds at the start of words (m-m-m-mommy), pause during speaking in the middle of sentences. This is associated with facial twitches and blinking. What do you recommend?

a. Audiology
b. Developmental assessment
c. Reassure
d. Refer to SLP

Answer 158

d. Refer to SLP

Question 159

Adolescent girl with bulimia who smokes 1.5 packs/day wants to quit, and is interested in nicotine replacement. Which of the following is a contraindication?

a) There is no contraindication
b) That she still smokes a few cigarettes once in a while
c) That she is <18 years old
d) Her eating disorder

Answer 159

a) No contra-indication: Only if you are post-op from some surgeries (Ie. Flap surgery with healing microvasculature) or severe cardiac disease

Eating disorder would be a contraindication to Buproprion

Question 160

What makes you worried about starting fluoxetine on a teenager with depression:

a. History of cardiac surgery
b. History of anxiety
c. Family history of bipolar disorder
d. Family history of suicide

Answer 160

c. Family history of bipolar disorder

Question 161

Name the criteria necessary for a diagnosis of Anorexia Nervosa (4 lines).

Name 3 physical characteristics that are seen with severe malnutrition.

Answer 161

Dx Criteria

a. Restriction of intake leading to significantly low weight
b. Intense fear of gaining weight, becoming fat even though significantly low weight
c. Disturbance in way body is experienced, undue influence of weight on self evaluation, lack of recognition of seriousness

PE
Lanugo
Scalp hair loss
Dry skin
Easy bruising
Goose flesh
Cold hands/ feet
Bradycardia
Orthostatic vitals
Hypothermia (<35.5)

Question 162

Father brings 3 y.o. child for suspected abuse. Multiple bruises acquired while staying with mom over weekend.

A) Three things required for immediate management in the E.R

B) Identify four radiological signs consistent with abuse.

Answer 162

A)

• Attend to medical needs of the child
• Clear documentation of history and PE
• Consultation with CPS
• Hx: previous bleeding/bruising, other injuries, response to Sx, PLT problems, meds, developmental Hx, psychosocial
• Labs: CBCd, smear, Pt/INR/PTT, Fibrinogen, von willebrand, blood group, Factor VIII + IX, Liver function, renal function
• Skeletal survey if <2

B)

• Age < 1 year
• Healing fractures of different ages
• Fracture not consistent with mechanism
• Multiple fractures
• Posterior rib fractures
• Metaphyseal fractures (corner/bucket handle)
• Femur # in non-ambulating child
• Humerus in <18mos
• Scapular or spinous process

Question 163

List 3 serious SE of Risperdol in addition to weight gain

Answer 163

• EPS: tardive dyskinesia, pseudoparkinsonism, akathisia, acute dystonic reaction
• Neuroleptic malignant syndrome
• QTc prolongation
• Seizures
• Hepatotoxicity
• Agranulocytosis
• Leukopenia/neutropenia
• Hyperprolactinemia
• Diabetes
• Hyperlipidemia
• Metabolic syndrome

Question 164

15 y.o. male brought in by parents because locked in room, hearing voices. Broke up with girlfriend two weeks ago.

A) What is the differential diagnosis? List four.

B) List four non-psychiatric diagnoses for psychosis/delirium

Answer 164

A) Substance use disorder
Brief psychotic disorder
Depression
Anxiety
OCD
Schizophrenia

B)Non-Psych:
Medications
CNS Infection
Autoimmune Encephalitis
Inborn Error of Metabolism
Thyrotoxicosis
SLE
Tumor 
Non-convulsive status
Porphyria

Question 165

6 y.o. With night terrors disturbing the whole family.

a) List 2 features that differentiate between night terrors and nightmares.
b) List 2 differential diagnoses
c) List 2 non-pharmacological approaches for night terrors

Answer 165

a) Night mares wake the child, remember them in the AM.
Night terrors earlier in night.
Night terrors - child hard to rouse during, consoling might makes them more combative

b) Ddx: confusional arousals, nocturnal seizures

c) Non Pharm approach:
- scheduled awakenings before event
- Nap to prevent from being over-tired

Question 166

Girl with PTSD – list 4 characteristics of PTSD

Answer 166

A. Exposure to actual threat of death, injury or sexual violence

B. Intrusive Symptoms a/w traumatic event (memories, dreams, flashbacks)

C. avoidance of stimuli associated with the event

D. negative alterations in cognition and mood a/w event (can’t remember details, negative beliefs, blame self, negative emotional state, detached)

E. Alteration in arousal or reactivity (irritable, reckless, hypervigilence)

F. Lasts >1 month
G. Causes distress/impairment

Question 167

Teacher thought 9yr boy hyperactive / inattentive. Not this way last year. Mom notices he breathes through his mouth.

3 further questions on history.

Answer 167

• Loud, frequent snoring
• Pauses in breathing while sleeping or choking/gasping
• Unusual sleep position
• Restless sleeping, sweating
• Hard to rouse in AM
• Daytime somnolence, napping
• Nasal congestion, hyponasal speech
• FHx

Question 168

A boy has been diagnosed with specific reading disorder.

List four features of this condition.

Answer 168

• struggles with decoding and word recognition
• poor handwriting
• difficulties in spelling
• good listening comprehension
• normal IQ
• comorbid ADHD

Question 169

You have a 2 yr old with newly diagnosed 22q11deletion.

Answer 169

• Congenital heart defects
• Hypocalcemia
• Immune abnormalities
• Hypothyroidism
• Cleft palate
• Renal abnormalities
• ? OSA

Question 170

You diagnose a child clinically with craniosyostosis. The child is not dysmorphic.

A. What is the most common type of craniosynostosis.

B. The XR confirms your diagnosis. What is your next step?

Answer 170

a. Sagittal synostosis (dolichocephaly or scaphocephaly)

b. refer to head shape clinic/neurosurgery

Question 171

5 yo boy with classic description of developmental coordination disorder (normal intelligence but fine motor abN, clumsy). What does he have?

Answer 171

Developmental Coordination Disorder

Question 172

Boy won’t speak at school, very shy. Speaks to parents at home.
Dx? Mgmt?

Answer 172

Selective mutism
CBT (w/ exposure therapy) +/- Fluoxetine
In classroom supports to give different ways of communication.
SLP

Question 173

A mom brings in 7 mth child with concerns of development. She has just started sitting independently. She babbles. She does not yet have a pincer grasp but mom thinks she is right handed because she will cross midline with her right hand to reach for an object presented on her left side.

A) What is your main concern?
B) List two reasons

Answer 173

A) Cerebral Palsy

B) Early handedness, not using left hand

Question 174

4 yo boy of single mom. Mom concerned that he is not longer napping. Sleep walking. Sleep 10-11 hours per night.
A) Name 2 things on history you would like to know.
B) What do you tell her about this particular sleep pattern?

Answer 174

A) Risk to injure himself? Family Hx?

B) Parasomnia - not distressing to child, will outgrow, Do regular good sleep hygiene - make sure he is not over tired

Question 175

List 3 classes of drugs and their targeted behavior or symptom in autism.

Answer 175

1. Stimulants - ADHD
2. SSRI - for repetitive behaviours
3. Antipsychotics - aggressive or self injurious behaviours
4. Melatonin - Sleep onset problems
5. Anti-epileptics - Seizures

Question 176

Childhood toxic stress can lead to problems with mental health in adulthood.

a) Name three examples of toxic stress that a child may be exposed to
b) What is the relationship between toxic stress exposure and poor outcomes in adulthood?

Answer 176

a)Physical Abuse
Domestic Violence
Sexual Abuse
Verbal abuse
Emotional neglect
Unstable housing
Divorce
Household member with mental illness
Incarcerated household member

b) Cumulative effect. Associated with poor outcomes including mental health, SES, cardiovascular health, employment, substance use

Question 177

A 13 year old girl has panic attacks that happen 3-4 times per day, lasting a few minutes at a time.

a) What are two elements on history would qualify this as a panic disorder (4 points)?
b) What are two treatment/management modalities (2 points)?
c) What would you suggest for her to do when she next experiences an attack?

Answer 177

a) History of panic attacks
- Fear of additional panic attacks or their consequences
- Maladaptive behaviour related to attacks (avoidance of situations)

b) SSRI, CBT
c) Develop coping skills and practice these before hand: deep breathing, grounding, shifting maladaptive thoughts.

Question 178

Six ways to decrease SIDS besides putting baby on back to sleep.

Answer 178

• No Smoking
• Sleep with baby in same room
• No co-sleeping in same bed
• No extra blankets or pillows
• Breast feeding
• Pacifiers
• If cosleeping - never when EtOH

Question 179

You seen an 18 month old boy with young parents. They are coming to you because he wakes up throughout the night, crying and screaming, and will only go to sleep with a bottle, in his mother’s arms, with soothing.

Answer 179

• Gradual extinction of maladaptive sleep associations.
• Stop feeding baby to sleep
• Stop rocking to sleep
• Put baby to bed in crib and reassure - eventually remove self from room
• Ferber - cry it out method
• Swap bottle to pacifier - only while falling asleep
• only use crib for sleeping

Question 180

A 16 year old girl with history of significant depression, started on risperidone a few months ago. She presents to you with galactorrhea.

1. What are three investigations you should do as a part of your management of a patient on risperidone?
2. She reports to you that her mood is significantly improved since starting the medication and she feels much better. What are two modifications you would suggest to her medication regimen?

Answer 180

1. Serum prolactin, fasting lipids and glucose. Height, Weight, BP. CBCd. Liver function tests.
2. Decrease the dose. Consider change to different antipsychotic (aripiprazol or quetiapine) - or SSRI!??!

Question 181

What are 4 strategies recommended by the CPS to prevent early childhood caries in First Nations/Inuit communities?

Answer 181

• Fluoride toothpaste
• Brush BID
• Fluoride varnish - 4times between 9 - 24 mos
• Reduce juice and sugary snacks
• Maternal dental care

Question 182

Baby with flattening of right side of his head.
A) most important sign to distinguish between positional and craniosynostosis (1)
B) 3 things you can do? (3)
C) 3 limitations to using the helmet? (3)

Answer 182

1. Positioning of ipsilateral ear - if posterior it is more worrisome
2. Tummy time, change direction baby sleeps in crib regularly, physiotherapy + stretching, encourage to look both ways with play + interesting objects
3. Cost, Limited evidence, need to wear 23h per day, skin breakdown, compliance.

Question 183

2 facial features specific for FAS? Two neuropsych symptoms of FAS (2)?

Answer 183

• Smooth philtrum
• Thin vermillion border
• Short palpebral fissures
• Anything ADHD
• ID
• Low tone

Question 184

Girl can’t take negative criticism. Socially inhibited.

Dx:

a. Depression
b. Avoidant personality disorder
c. Social phobia
d. Generalized anxiety disorder

Answer 184

c. Social phobia

? probably the best info with this limited stem.

Question 185

A teen is on prozac and risperadol for six months and now experiences ataxia, decreased concentration
etc. What to do.

1. increase prozac
2. decrease prozac
3. eliminate Prozac
4. increase risperadol
5. decrease risperadol

Answer 185

5. decrease risperadol

Sounds like EPS from risperadol

There is an interaction between prozac and risperadol (where prozac inhibits the cytochrome that risperadol uses)