60 ABPN Child and Adolescent Psychiatry Board Exam Practice Questions

Diffuse cerebral atrophy is correct because Huntington’s disease, the most likely diagnosis given the patient’s and his mother’s symptoms, is associated with progressive brain atrophy, particularly in the caudate nucleus but also observable as diffuse cerebral atrophy as the disease advances. This reflects the widespread neurodegenerative process characteristic of Huntington’s disease.

Abnormal posterior fossa with atrophy of dentate nucleus is incorrect because this finding is more indicative of cerebellar disorders, such as spinocerebellar ataxias, rather than Huntington’s disease, which predominantly affects the caudate nucleus and leads to diffuse cerebral atrophy.

No change in CT scan is incorrect because Huntington’s disease is known to cause structural changes in the brain, including atrophy, that would be visible on a CT scan as the disease progresses.

Bilateral atrophy of the globus pallidus is incorrect because, although Huntington’s disease can affect various parts of the brain, the hallmark feature is atrophy of the caudate nucleus and diffuse cerebral atrophy, not specifically the globus pallidus.

Diffuse white matter changes is incorrect because, while white matter changes can occur in a variety of neurodegenerative and demyelinating diseases, the characteristic finding in Huntington’s disease is neuronal loss and atrophy, particularly in the caudate nucleus and as diffuse cerebral atrophy, rather than widespread white matter changes.

Fetal hydantoin syndrome is correct as it is caused if the fetus is exposed to antiepileptic drug during pregnancy. It is characterized by abnormalities in limbs, central nervous system abnormalities, cleft lip and palate, and ocular defects present in this baby. Phenytoin has teratogenic effects and causes various defects in the developing fetus.

Down syndrome is incorrect as it is characterized by upward slanting of eyes, hypotonia, short neck with excess skin, brachycephaly, low set ears, simian crease, and clinodactyly. The most common heart defect is endocardial cushion defect and ventricular septal defect. Down syndrome is a genetic disorder caused by a full or partial extra copy of chromosome 21.

Hydrops fetalis is incorrect as it is caused due to a complication of the newborn’s hemolytic disease. The baby has skin edema, pericardial effusion, pleural effusion, and ascites. They have severe anemia, shortness of breath, and hepatosplenomegaly. The survival rate is low in these babies.

Edward syndrome is incorrect as it is characterized by low birth weight, wide-spaced eyes, drooping of the upper eyelid, microcephaly, underdeveloped jaw, and low-set ears. Babies also have rocker-bottom feet, clenched hands, kidney, and gastrointestinal defects.

Fetal alcohol syndrome is incorrect as it is caused in babies exposed to alcohol in fetal life. It is characterized by a thin upper lip, underdeveloped midface, upturned nose, and flat philtrum. The babies may also have deformities of growth, joints, limbs, visual, and hearing difficulties.

Prader Willi syndrome is correct as children usually present in infancy with feeding problems, hypotonia, low birth weight, and later gain a lot of weight. This child is obese, with typical features (almond-shaped eyes, thin upper lip, temper issues) suggestive of Prader Willi syndrome. They have mild to moderate mental retardation, hypotonia, violent outbursts, and temper issues. It is a genetic disorder caused by a defect on the long arm of chromosome 15.

Hypothyroidism is incorrect as it presents with developmental delay, constipation, weight gain, dry skin, and poor academic performance. This child has symptoms and signs suggestive of Prader Willi syndrome and will need management for it. Children with Prader Willi syndrome have short stature, hypogonadism, and have deficiency of growth hormone, adrenal insufficiency, and hypothyroidism.

Down syndrome is incorrect as it is characterized by typical facies small chin, flat nasal bridge, slanted eyes, protruding tongue, single palmer crease, and developmental delay, which are absent in this patient. It is a genetic disorder also known as trisomy 21, and children have intellectual and physical delays. Many Down syndrome patients are noted to have a single palmer crease in hands.

Russell Silver syndrome is characterized by intrauterine growth retardation, low birth weight, feeding difficulties, poor growth and weight gain after birth, clinodactyly, prominent forehead, small jaw, narrow chin, triangular face, and developmental delay. This child has signs and symptoms of Prader Willi syndrome and will need confirmation with genetic analysis.

Angelman syndrome is incorrect as it is characterized by developmental delay but the child?s personality is excitable and happy, which is not the case with this child. Children with angelman syndrome also have intellectual disabilities, seizures and problem with speech. This child has symptoms and signs suggestive of Prader Willi syndrome and will need confirmatory diagnosis by genetic analysis.

Bonding with a transitional object is correct. The blanket has become an object to compensate for the mother when the girl is at school, as it corresponds with the mother’s attributes. It provides psychological comfort and acts as a substitute for the mother as the child has started developing independence.

Social anxiety disorder is incorrect as it usually occurs around 12 years of age, with children being anxious and fearful of embarrassment in social situations, which is out of proportion to the actual situation.

Oppositional defiant disorder is incorrect as her irritability and strong refusal to permit her blanket to be removed is not due to outright defiancy, anger, or vindictiveness; rather is part of her need for psychological comfort. The girls symptoms have not been present for 6 months and in oppositional defiant disorder, children are willing to lose an item or privilege rather than lose “face.” Here, the girl wants to avoid losing her blanket above all else.

Attention-deficit hyperactivity disorder is incorrect in that children are hyperactive, easily distracted, and inattentive with ADHD but not seen as sad. Of note, symptoms are present in this child only a few months and ADHD symptoms must be present for 6 months.

Conduct disorder is incorrect as it usually presents in adolescence and is associated with aggressive, deceitful, and destructive behavior. Children do not follow the rules and are involved in bullying, lying, and stealing.

Language disorder is the correct response because the chief complaint of the patient is related to grammar and vocabulary, which comprise the syntax and semantics of language respectively. He is unable to employ appropriate words, tenses, and grammatical rules in his speech, all of which point towards the diagnosis of language disorder.

Autism spectrum disorder is an incorrect response because this patient has no problems related to social interaction, reciprocity, or stereotyped behaviors/ restricted interests which are hallmarks of this condition.

Speech disorder is incorrect because there is no evidence of difficulties in his articulation or vocalization of speech.

Social communication disorder is incorrect because the child does not only show specifics in using language solely for the purpose of communication in social settings. He is able to use non-verbal cues and gestures appropriately.

Nonverbal communication disorder is incorrect as he uses appropriate gestures and facial expressions during communication.

Polysomnography is the correct response because the patient most likely suffers from obstructive sleep apnea, which commonly presents with excessive daytime sleepiness and loud snoring at night. Down syndrome, obesity, and tonsillar hypertrophy are risk factors for developing obstructive sleep apnea. Polysomnography, also known as inpatient sleep study, is the gold-standard confirmatory test for diagnosing obstructive sleep apnea. This involves oximetry along with video-recording of the patient while he sleeps in a room specifically adapted for sleep studies. The diagnosis of sleep apnea is confirmed if there are more than 10-15 apneas in any 1 hour of sleep.

Tonsillar biopsy is incorrect because tonsillar hypertrophy is merely a risk factor for developing sleep apnea, and the biopsy findings do not help in establishing the diagnosis of sleep apnea.

Overnight pulse oximeter desaturation study is incorrect because it is outdated and no longer used in clinical practice and secondly, because it is an initial test, not the confirmatory test.

Echocardiography is incorrect because it is not a diagnostic test for sleep apnea.

Continuous positive airway pressure (CPAP) is incorrect because it is a treatment modality of obstructive sleep apnea, not a diagnostic test.

Family counseling for improved parental monitoring is the correct response because family-based interventions, like improved parental monitoring and promoting adolescent self-control, are ideal prevention strategies in cases that are at risk for alcohol abuse. Since the teen in this case is not a chronic alcoholic and he, himself, is determined to abstain from alcohol, the parents must be counseled for implementing these family-based prevention strategies.

Intramuscular injection of naloxone is an incorrect option because it is the pharmacotherapy used for alcohol abstinence in cases of chronic alcoholism particularly when psychotherapy has failed to produce effective results.

Enrollment in drug abuse resistance education is incorrect because drug education alone has not been shown to be effective in preventing alcohol abuse.

Individual cognitive behavioral therapy is not yet a preferred treatment of choice when there is not yet a formal substance use disorder diagnosis nor are there any other DSM diagnoses as presented in this case. The child in this case is determined not to use alcohol; therefore, prevention strategies are more appropriate as compared to treatment strategies.

Prescribing acamprosate and disulfiram is an incorrect option as these are pharmacotherapies employed for alcohol abstinence in patients in whom psychotherapy has not proven to be effective.

Sertraline is correct as this patient has major depressive disorder (MDD). In this psychiatric disorder, 5 or more of the designated symptoms should be present for at least 2 weeks and at least one of the symptoms is depressed or irritable mood or loss of interest or pleasure. The following are the other symptoms: appetite or weight changes (or, in children, the lack of expected gain), changes in sleep, observed psychomotor agitation or retardation; fatigue or loss of energy; feelings of worthlessness or excessive or inappropriate guilt; diminished ability to think or concentrate, or indecisiveness; recurrent thoughts of death or recurrent suicidal ideation. Among antidepressant medications, selective serotonin reuptake inhibitors (SSRI) are generally the initial medications used to manage depression. Sertraline is the only SSRI among the options; thus, it is the correct answer.

Imipramine is incorrect because it is a tricyclic antidepressant (TCA) and used to be the mainstay treatment up to the late 1980s.

Phenelzine is a monoamine oxidase inhibitor (MAOI) and is not a first-line medication. Patients who take MAOIs need to avoid tyramine. This drug class also has potential drug interactions.

Risperidone is an antipsychotic that is not commonly used to treat major depressive disorder (MDD), especially when the MDD is not accompanied by psychosis.

Olanzapine is an antipsychotic that is not commonly used to treat major depressive disorder (MDD), especially when the MDD is not accompanied by psychosis.

Psychodynamic psychotherapy is correct because this technique targets intrapsychic conflicts, and its goal extends beyond symptom relief. It takes into account the psychopathology of difficult and problematic behaviors and explores how life events and evolving defense mechanisms of children and adolescents affect their current symptoms.

Relaxation training is incorrect because this technique uses breathing control exercises along with muscle relaxation training; it does not aim to resolve intrapsychic conflicts. It is mainly used for anger management and sometimes for insomnia.

Exposure therapy is incorrect because it refers to exposing the individual to a feared situation or trigger in a controlled environment; it does not aim to resolve intrapsychic conflicts. It is a technique of cognitive-behavioral therapy that is most commonly used for the treatment of anxiety disorders, such as specific phobias and obsessive-compulsive disorder.

Habit reversal training is incorrect because it is mainly used for disorders characterized by repetitive behaviors such as Tourette syndrome and other tic disorders, nail picking, and trichotillomania. It aims at identifying the triggers of unwanted behaviors and then developing competing responses to them.

Interpersonal psychotherapy is incorrect because its primary goal is to improve interpersonal relationships and enhance an individual?s social functioning.

Clarify to the parent that confidentiality is one-way in this case is correct because, in this form of psychotherapy, the therapist is allowed to share what parents may have said about the child, but he would not share with parents any of his/her communications with the child. The primary relationship in psychodynamic therapy is between the therapist and the child; parents only facilitate that relationship. Psychodynamic therapy targets intrapsychic conflicts, and its goal extends beyond symptom relief. It takes into account the psychopathology of difficult and problematic behaviors and explores how life events and evolving defense mechanisms of children and adolescents affect their current symptoms.

Ensure that both the parent and child are present in all sessions is incorrect because the goal of this form of therapy, known as psychodynamic therapy, is to help the child explore his thoughts and feelings. The therapist should strive to create a suitable environment where the child does not feel obliged to act in a certain manner. Like all patient-physicians relationships, confidentiality is important and would be compromised in the presence of a parental figure.

Implement a flexible schedule for appointments to foster trust is incorrect because that would be counterproductive. Establishing a set schedule is necessary for defining the boundaries of the therapeutic relationship.

Deal with the child in a directive and confrontational manner is incorrect because the therapist should adopt a facilitative and nonconfrontational approach in this form of psychotherapy. Otherwise, the child or adolescent will become defensive and will not be able to fully participate in the therapy.

Keep the parents as uninvolved as possible is incorrect because they play an important role in helping the therapist understand the context behind the thoughts and behaviors of the child, especially at the beginning of the therapy.

Pyromania is the correct answer as DSM-5 classifies pyromania as a condition in which a patient intentionally sets fire on more than one occasion with no apparent motive such as political gain, revenge, profit, etc. The pyromaniac experiences tension or arousal before the act of fire setting.

Conduct disorder may also present with fire-setting episodes, but this patient doesn’t meet all criteria for conduct disorder as conduct disorder requires 3 of 15 symptoms from these key categories: aggression towards people or animals, destruction of property, deceitfulness or theft, and serious violation of rules.

Attention-deficit hyperactivity disorder (ADHD) presents with inattentiveness and or-hyperactivity. This boy doesn’t have such symptoms.

Trichotillomania is incorrect because these patients have increased obsession to pull out their hair.

Oppositional defiant disorder (ODD) is incorrect because a patient with this would have irritable mood with defiant behavior towards authority figures but no criteria (setting fires).

Methylphenidate is the correct answer because the vignette describes a case of attention deficit hyperactivity disorder (ADHD), where it is the best option for treating the condition. It is a stimulant drug, and common side effects include nervousness, tachycardia, loss of appetite, nausea, abdominal pain, insomnia, and growth retardation may occur with prolonged therapy.

Propranolol is a beta antagonist drug which is used to treat different anxiety disorders and phobias. The main side effects of this drug include decrease in heart rate or dizziness.

Risperidone is a second-generation antipsychotic which has many indications, but it is not used for treating core ADHD. The main side effects of risperidone are weight gain, metabolic syndrome, increased prolactin, and extrapyramidal side effects.

Sertraline is an SSRI, which is an antidepressant class of medications. It is not used to treat ADHD and does not cause palpitations.

Buspirone is an anxiolytic which causes dizziness, blurred vision, headache, etc.

Cognitive-behavioral therapy is the correct answer because it is one of the first-line treatment choices for adolescents with major depressive disorder (MDD), especially as antidepressants may be problematic in patients with a strong family history of bipolar disorder.

Venlafaxine is incorrect because it is a serotonin-norepinephrine reuptake inhibitor (SNRI) which is not approved by the Food and Drug Administration (FDA) for use in children and adolescents and studies have not shown any evidence of efficacy in the treatment of MDD in adolescents. Hence it is not recommended in this population.

Electroconvulsive therapy (ECT) is incorrect as it is considered if there is no response to treatment to 3 antidepressant medications.

Lithium is incorrect as it is a mood stabilizer that has shown efficacy as an augmentation agent.

Paroxetine is incorrect because although it is also an SSRI, it is not recommended for the treatment of MDD in adolescents as it has shown no efficacy when compared to placebo.

Risperidone, which, according to cognitive testing done in children with intellectual disability having concurrent disruptive behavior, has shown to be having good control over behavioral issues. Risperidone is an atypical antipsychotic which has a role in controlling the comorbidities commonly associated with an intellectual disability like autism spectrum disorder, disruptive behavior, and self-injurious behavior in the population described and has similar efficacy and better tolerability than typical antipsychotics. Despite risks of metabolic abnormalities, when appropriately monitored, risperidone has a better safety profile long-term as compared to typical antipsychotics due to their risk of tardive dyskinesia.

Thioridazine is incorrect as it is an older typical antipsychotics.

Haloperidol is incorrect as it is an older typical antipsychotics.

Chlorpromazine is incorrect as it is an older typical antipsychotics.

Methylphenidate is incorrect as it is a stimulant that is used to increase the ability to maintain attention in children with attention-deficit/hyperactivity disorder, existing concurrently with below-average intellect.

Clonidine, or guanfacine, is the preferred first line treatment medication options for patients with comorbid ADHD. These alpha2 agonists (which are not FDA approved for TS) have less effect than haloperidol but a much more preferable side effect profile. For non-ADHD patients, VMAT2 inhibitors (tetrabenazine or deutetrabenazine) are also viewed as potential medication alternatives for TS, and antipsychotics are generally viewed as the last line.

Olanzapine is an effective pharmacotherapy agent for TS, but it is not considered the first line due to the significant adverse effects.

Haloperidol, a dopamine D2 receptor antagonist, is incorrect. Although it is effective in the short term in the treatment of TS its side effect profile should prevent it from being used first line. It is FDA approved for the treatment of TS (along with aripiprazole and pimozide), but despite this indication clonidine is a safer choice. It is considered a second- or third-line pharmacotherapy agent because of the risk of developing tardive dyskinesia and extra-pyramidal symptoms. Long-term effectiveness of haloperidol is less favorable.

Risperidone is an effective pharmacotherapy agent for TS, but it is not considered the first line due to the significant adverse effects.

Ziprasidone is an effective pharmacotherapy agent for TS, but it is not considered the first line due to the significant adverse effects.

Selective mutism is correct as it refers to an anxiety disorder that is characterized by a consistent failure to speak in certain social situations where there is an expectation to speak (e.g., at school) despite speaking normally in other situations. Children with selective mutism do not suffer from a language impediment and may speak when they are in the company of immediate family members but often may not even speak in the presence of second-degree relatives or close friends. They may refuse to speak at school, which results in academic or educational impairment. Children with this condition sometimes use nonverbal means, e.g., writing, drawing, pointing, or grunting, to communicate and may be eager to engage in social encounters where speech is not required.

Autism spectrum disorder is characterized by problems in social interaction or communication as well as by repetitive or ritualistic patterns of behavior and restricted interests.

Reactive attachment disorder is a disorder of infancy or early childhood that is characterized by developmentally inappropriate and markedly disturbed attachment behaviors, in which a child very rarely or minimally seeks comfort, protection, and support from an attachment figure.

Disinhibited social engagement disorder is incorrect as it is characterized by culturally inappropriate and excessively familiar behavior with relative strangers.

School phobia is incorrect because diagnosed children may refuse to go to school; however, they do not exhibit problems in communicating through language.

Individuals with panic disorder may experience both expected as well as unexpected panic attacks is correct. A panic attack refers to a sudden surge of intense fear during which four or more out of the thirteen physical and cognitive symptoms described in the DSM-5 criteria may occur. These symptoms may include shortness of breath, palpitations, sweating, shaking, chest pain, feelings of choking, paresthesias, nausea, dizziness, chills or heat sensations, derealization or depersonalization, or a feeling of dying or “going crazy.”

The presence of unexpected panic attacks rules out the diagnosis of panic disorder is incorrect. Unexpected panic attacks lack an obvious trigger or cue, whereas an obvious trigger or cue is present in case of expected panic attacks. Individuals with panic disorder may experience both expected as well as unexpected panic attacks. Therefore, the diagnosis of panic disorder is not ruled out by the occurrence of expected panic attacks.

Panic attacks always arise from a calm state is incorrect because they could arise either from an anxious state or from a calm state. Similarly, a panic attack may return to a calm state or an anxious state and then possibly peak again.

Individuals with panic disorder experience panic attacks only in response to circumscribed phobic situations or objects is incorrect because the attacks do not occur only as a response to circumscribed phobic situations or objects, as is seen in specific phobias.

Individuals with panic disorder do not experience limited-symptom panic attacks is incorrect. In terms of severity, patients with panic disorder may experience both limited-symptom (less than 4 symptoms) and full-symptom (4 or more symptoms) panic attacks. However, to establish the diagnosis of panic disorder, at least one of the attacks must be followed by 1 month (or more) of persistent concern or worry about additional attacks and/or a maladaptive change in behavior related to the attacks.

Reactive attachment disorder (RAD) is the most likely diagnosis as the disorder presents in children between nine months to five years of age who have been severely neglected for most of their early childhood. Children with RAD display disturbed attachment to the guardian who provides comfort and care; there is a lack of positive affect and limited response to support from the caregiver.

Disinhibited social engagement disorder is incorrect because it is characterized by overly friendly and open interaction with strangers.

Autism spectrum disorder is incorrect as the boy does not exhibit characteristics of autism such as restricted interests, repetitive behaviors, or sensory deficits.

Intellectual disability is unlikely as the boy is reported to have normal developmental milestones and children with intellectual disabilities typically have normal emotional regulation towards caregivers.

Depressive disorder is incorrect because while a child with a depressive disorder may present with a negative effect, they would still respond adequately to comfort and care.

Divalproex sodium is correct because this question describes a patient with polycystic ovary syndrome. Divalproex sodium is an anticonvulsant that may be used for stabilizing mood and behavior in pediatric bipolar disorder. Anticonvulsants are not approved by the FDA for the treatment of bipolar disorder in the pediatric population. Divalproex is associated with several rare but severe adverse effects: thrombocytopenia, pancreatitis, hypothermia, hyperammonemic encephalopathy, and multi-organ hypersensitivity reactions. Prevalent dose-related side effects with divalproex sodium include gastrointestinal (nausea, vomiting, dyspepsia, diarrhea), hepatic (deranged LFTs), central nervous system (tremor, sedation, dizziness), and metabolic (weight gain, osteoporosis) problems, and hair loss. Divalproex sodium has been associated with major congenital malformations like neural tube defects. It is FDA pregnancy category D.

Lithium is not found to be associated with a higher risk of PCOS.

Carbamazepine is not found to be associated with a higher risk of PCOS.

Lamotrigine is not found to be associated with a higher risk of PCOS.

Olanzapine is not found to be associated with a higher risk of PCOS.

To observe for differences in patient’s mental status and to give the patient a chance to speak for himself is correct because, for an older child, the consultant needs to observe the differences in mood and affect with and without the presence of the family. Furthermore, the patient should be given the opportunity to describe the situation from his perspective.

To understand parent’s experience of past medical care is incorrect because to achieve such an understanding, the consultant would need to interview the parents rather than the child alone.

To help the parents be attuned to the patient’s actual needs is incorrect because meeting the child alone is unlikely to help the parents better understand the patient’s needs. Helping the parents better attune themselves to the child’s actual needs would require helping them differentiate between the patient’s past and present medical situation. This would certainly involve interviewing the parents, which is likely to be done after the teen is seen alone.

To improve the parent and child relationship is important but would not occur quickly nor be the first reason to interview the child alone. Such an improvement would require multiple visits after having interviewed the teen alone, the parents alone, then the family together.

To understand patient’s socioeconomic status is incorrect because a meeting with the patient alone is generally required to make the child feel comfortable with sharing private concerns and for the consultant to observe for any differences in the patient’s mental status, with and without the family’s presence.

Uncover self-blaming misconception is the correct response because children in the 3-4 years age range, as in this scenario, are known to possess a combination of egocentricity and illogical thinking. They are known to proscribe self-blame to their suffering. Therefore, it is necessary to uncover and correct any self-blaming misconceptions the child might harbor.

Explain illness simply is incorrect because a younger child aged 3-4 years, as in this case, is generally egocentric and preoperational, unable to understand simple explanations while believing that everything bad happening to them might be a direct cause of their actions.

Explain treatment options clearly is incorrect because the child in this scenario is too young to understand simple, clear explanations of medical conditions. A 7-12-year-old child will be able to understand if treatment options are clearly explained.

Seek assent from the 3 year old before procedures is incorrect because the child is a 3-year-old who does not possess the cognitive maturity to understand functional explanations of medical conditions. Assent can be sought from a child 7-12 years of age who can better understand his condition.

Seek consent from the 3 year old before treatment initiation is incorrect because the child is only 3 years old, lacking cognitive maturity. Consent is generally sought from adolescents who display the cognitive ability to understand the purpose of treatment and the ramifications of refusal.

Child abuse is correct because the patient has presented with marks of physical injury for which his foster parents have provided conflicting excuses. The primary care physician should notify the Department of child protective services.

Delirium is incorrect because the child has not presented with an acute confusional state and has no cognitive impairment or arousal disturbance.

Anorexia nervosa is incorrect because the child has not presented with a history of avoiding or restricting food intake; he is described as healthy

Nonadherence is incorrect because the child, in this case, has not presented with a refusal to adhere to a previous treatment regimen which puts his life at risk.

Psychosomatic illness is incorrect because the patient in this scenario has not presented with intense, persistent somatic complaints. The child has croup and there is physical evidence suggestive of abuse.

Place student in an alternative setting after clarifying he does not warrant a psychiatric hospitalization and is free of both homicidal and suicidal thoughts is correct because school officials now have the authority to remove a student and place him in an alternative setting if a weapon is brought to the school. The alternative setting may be helpful, too, as it removes him from the alleged threat he perceived and gives the school an opportunity to investigate. Still, the boy has violated an important school rule and should meet the consequences of his actions.

Assign tasks for the student to focus on is incorrect; it will not serve as any form of behavior modification or reason to alter such a high-risk offense.

Help the student to identify an automatic negative thought is incorrect. This may be of help down the line after securing his safety, others’ safety, and after he has been accessed for possible depression. Identifying an automatic negative thought can be of help as part of a cognitive behavioral treatment for depression, yet this student has not been identified as being depressed.

Encourage use of snacks to enhance functioning is incorrect because such an intervention is not likely to have any impact on this student

Define classroom expectations in positive terms is incorrect because, at this juncture, is not likely to have an impact on this teen.

Post-traumatic stress disorder (PTSD) or acute stress disorder is correct because the child exhibits features of post-traumatic stress following a transplant procedure, and the anxiety expressed by his parents may be a strong predictor of the child’s traumatic reaction.

Attention deficit hyperactivity disorder (ADHD) is incorrect because the patient has not presented with any symptoms of inattentiveness which are a prerequisite for a diagnosis of ADHD.

Hormonal imbalance is incorrect. This child may be experiencing severe anxiety, fears of dying and has had known nightmares with avoidance. There is no evidence of a hormonal imbalance in this scenario.

Conduct disorder is incorrect because the child does not display aggression, deceitfulness, or serious violation of rules.

Oppositional defiant disorder is incorrect because the patient in this scenario has not presented with a pattern of more than 6 months of argumentative, defiant, and vindictive behavior, resulting in impaired functioning.

Shared decision-making is correct because in a collaborative team model used in this scenario, the medical team and the psychiatric consultant share decision-making and responsibility for patient care.

Lack of follow-up is incorrect because, in the collaborative team approach, the psychiatrist and the medical team provide shared caregiving, while a lack of follow-up is common in a resource consultation model.

Lack of patient contact with the psychiatrist is incorrect because, unlike the collaborative team model used in this scenario which requires a team effort by the medical team and psychiatrist for patient care, an educative process model is more likely to involve little direct patient contact with his psychiatrist.

Psychiatrist limited to the specific diagnostic question is incorrect because a collaborative team model involves a holistic level of care afforded by the psychiatrist who is equally involved in patient management. The psychiatrist is limited to a specific diagnostic question in cases where a resource consultative approach is used (typically).

Offer indirect psychiatric support to the family is incorrect because the collaborative team approach requires direct involvement.

Corticosteroids is correct. The patient has presented with complaints of episodes of mania and a history of weight gain, body aches, easy bruising, and hirsutism following drug administration. These adverse effects are all typically associated with high-dose corticosteroids which ideally, are tapered over several months.

Cyclosporine is incorrect because a known hypersensitivity to polyoxyethylated castor oil, an ingredient of the cyclosporine drug formulation, as in this case, is a contraindication to cyclosporine use. The patient has not presented with the typical delirium and auditory, visual hallucinations linked with high-dose cyclosporine use. Carbamazepine is also known to reduce cyclosporine levels through hepatic induction, while the patient was not advised to change his antiepileptic drug regimen in this scenario.

Tacrolimus is incorrect because a known hypersensitivity to polyoxyl 60 hydrogenated castor oil, an ingredient of the tacrolimus drug formulation, is a contraindication to its administration as in this case. The patient has also not presented with hallucinations, delirium, or akinetic mutism, characteristic clinical features of high-dose tacrolimus.

Mycophenolate mofetil is incorrect because the patient has not presented with the features of depression, anxiety, or sedation typically seen following mycophenolate administration. A history of weight gain, body aches, easy bruising, and hirsutism is not linked to mycophenolate mofetil use.

Muromonab-CD3 OKT3 is incorrect because the patient does not present with features of aseptic meningitis and does not possess a history of hallucinations during drug administration. OKT3 is a monoclonal antibody reserved for the immediate postoperative period to prevent rejection.

Epilepsy is correct because it possesses a high seizure potential according to studies and can induce seizures in patients with epilepsy or those with lower seizure threshold. In the given scenario, the patient is depressed and needs an anti-depressant, which should be other than bupropion.

Polycystic ovarian syndrome (PCOS) is incorrect because it is not an absolute contraindication to the use of bupropion.

Hypercholesterolemia is incorrect because it is not an absolute contraindication for bupropion use since it does not influence lipid metabolism significantly.

Diabetes is incorrect because it is not an absolute contraindication to bupropion use.

Hypertension is incorrect because it is not an absolute contraindication but requires frequent dosage and side effect monitoring due to the risk of heart failure.

Attention-deficit hyperactivity disorder (ADHD) is correct because it is characterized by inattention and hyperactivity. These children have much difficulty staying on task, being organized, and are often fidgety, restless, and impulsive.

Autism spectrum disorder is incorrect because it is characterized by abnormal social interaction and impaired verbal and non-verbal communication.

Oppositional defiant disorder (ODD) is incorrect because it is characterized mainly by persistent argumentativeness, anger, and defiant behavior.
ODD does overlap with ADHD in many children, but even some ODD-like traits will often improve once the ADHD is treated.

Tourette’s disorder is incorrect because it is characterized by both motor and vocal tics. The tics are present throughout the day and may occur in bouts.

Generalized anxiety disorder is incorrect because it is characterized by worry with many physical complaints.

Bipolar I disorder is correct because it is characterized by at least one manic episode in which the patient appears elated and grandiose. He expresses expansive ideas, flight of ideas, and garrulousness. There is a decreased need for sleep, while energy levels and libido are increased.

Delusional disorder is incorrect because it is characterized by the presence of one or more delusions usually based on a particular theme which have been present for a month. If any mood disturbances have been present, the disturbance is brief relative to the delusional period. For this diagnosis to be given, there cannot be a mental disorder that better explains the symptoms. In this case, mania as seen in Bipolar illness is a more appropriate mental diagnosis than Delusional disorder.

Bipolar II disorder is incorrect because it is associated with a major depressive episode and a hypomanic episode. This teen has actual mania with a one-week history of elevated mood along with grandiosity, decreased need for sleep, flight of ideas, and excessive talking. For Bipolar II, the hypomania lasts 4 days and is less severe in its presentation, not causing marked impairment. In this 17-year-old, marked impairment is described, particularly at school.

Schizophrenia is incorrect because it is characterized by delusions, hallucinations, and grossly disorganized, odd behavior. There is an effective blunting or restricted range of emotions.

Frontal lobe syndrome is incorrect because it is an organic brain disorder caused by head trauma, cerebrovascular accident, tumors, or epilepsy.

Floxetine is correct because this patient likely has obsessive compulsive disorder (OCD), with obsessions around germs and cleanliness. The first line treatments include CBT-ERP (cognitive behavior therapy with exposure and response prevention) and selective serotonin reuptake inhibitors (SSRI.) Fluoxetine has an FDA indication for pediatric and adult OCD treatment. and is a good modality in reducing the symptoms of OCD. The disorder can cause extreme anxiety in the patient and a great deal of discomfort and impairment of functioning due to repetitive, compulsive actions. Oftentimes serotherapeutic doses of SSRIs are required to adequately treat OCD.

Propranolol can be used off-label for social anxiety disorder, performance only. There is no indication for it being used with OCD.

Alprazolam is incorrect because it is useful in treating specific phobias and panic disorders but has no role in controlling obsessions and compulsions.

Buspirone is incorrect because it is indicated in the treatment of generalized anxiety disorder.

Olanzapine can be used in refractory cases of OCD as an adjunct to SSRIs, but are not used as a 1st line treatment.

Autism spectrum disorder is correct because it is characterized by abnormal social interaction and impaired verbal and non-verbal communication. The children exhibit repetitive, stereotyped behavior and are painfully inflexible to even minute changes in their routine. Speech development is often severely impaired to the extent of babbling at later ages or producing strange incoherent sounds. Inability to maintain eye contact is common in children with Autism. Interests are markedly restrictive.

Attention-deficit hyperactivity disorder (ADHD) is incorrect because it is characterized by inattention and hyperactivity. These children are unable to maintain attention on a single task, even while playing. They are usually messy and unable to remain organized or perform tasks that require sustained mental efforts. They are extremely restless, fidgety, and often squirm in the seat but are sociable, and at times, can be charming.

Tourette’s disorder is incorrect because it is characterized by both motor and vocal tics. The tics are present throughout the day and may occur in bouts.

Avoidant personality disorder is incorrect because personality disorders are not diagnosed at such young ages.

Schizoid personality disorder is incorrect because it is characterized by emotional aloofness and personality disorders are not diagnosed in this age group as personality is still in its early stages of development.

Risperidone is correct because the most likely diagnosis, in this case, seems to be autism spectrum disorder (ASD) due to poor verbal and nonverbal communication, repetitive behaviors, and a history of associated aggression. According to the guidelines based on clinical trials, risperidone effectively controls anger outbursts and irritability in patients with autism spectrum disorder and is considered the first-line agent. Risperidone has proven efficacy in controlling aggression and self-injurious behavior in children and adolescents with autism spectrum disorder.

Haloperidol is incorrect because it is not now considered a first-line agent for managing irritability and aggression in patients with ASD.

Olanzapine is incorrect because it is not considered a first-line medication in ASD.

Clozapine is incorrect because it is not a first-line agent.

Quetiapine is incorrect because it is not a first-line agent.

Desmopressin is correct because the case describes a patient with nocturnal enuresis, which is defined as recurrent, involuntary voiding of urine onto the bed, in the clothes, etc., after the age of 5 years. The first-line treatment includes behavioral modification techniques by setting alarms, rewarding the child when there is no bedwetting, etc. However, when these strategies fail, pharmacologic agents may be used. The first-line pharmacologic agent is desmopressin, a selective vasopressin receptor agonist and mimics endogenous ADH. The drug counters excessive urine production at night, thereby reducing bedwetting. Studies have shown an active role of desmopressin in controlling enuresis, but the condition can revert when the treatment is stopped.

Benztropine is incorrect because it may induce urinary retention as a side effect that might help treat enuresis, it is not a first-line treatment option and is not commonly used.

Imipramine is incorrect because it is beneficial in subsets where desmopressin has not yielded results or can be considered a second-line pharmacological agent due to cardiotoxicity and hepatotoxicity.

Fluoxetine is incorrect because it is a selective serotonin reuptake inhibitor (SSRI) and is not indicated for enuresis

Trazodone is incorrect because it is an anti-depressant drug with no role in treating nocturnal enuresis.

Rett syndrome is correct as it is a genetic disorder affecting brain development, which present in girls. It is characterized by children being normal for the first 6+ months and then losing the ability to walk, eat, and sleep. They have repetitive purposeless hand movements like wringing or clapping, which is present in this child. Rett Syndrome has was removed from the DSM5 and now is 1 of the 5 autism-related conditions.

Cerebral palsy is a motor disability that affects the ability to maintain balance and move. It is due to abnormal brain development, and the child may be floppy or rigid (hypotonic and hypertonic) with exaggerated reflexes. This child had achieved her milestones normally till one year of age, so cerebral palsy is unlikely.

Reactive attachment disorder is a trauma and stressor-related disorder that happens in response to traumatic/neglectful early caregiving experiences. These children can have neurodevelopmental delays, but it is not required for a diagnosis.

Tourette syndrome is a neurological disorder that starts in childhood. It presents with involuntary movements or sounds like blurting of words or shoulder shrugging. This child does not have tics and has repetitive hand movements suggestive of Rett syndrome.

Attention deficit hyperactivity disorder presents with inattention, impulsivity, and hyperactivity in at least 2 different settings. This girl has abnormal behavior and hands wringing movements, which are suggestive of Rett syndrome.

Personal fable is when adolescents believe that none of the difficulties and issues of life will affect them. It is an identifier of adolescent egocentrism. Individuals have a certainty that whatever risk-taking behavior is adopted, nothing will affect them due to the belief that them being untouchable and exclusive. This adolescent is involved in the ingestion of drugs and drinking beer but still believes he will never get sick and does not need therapy.

Identity diffusion is a stage of self-identity characterized by the individual lacking exploration or commitment for his goal in life. These adolescents have a low drive to explore opportunities and ideas and commit to a specific aim.

Hypotheticodeductive thinking is characterized by the development of cognition skills in the adolescent to make a hypothesis. It enables the individual to check his hypothesis with reality. They learn new cognitive tasks and deductive reasoning, which moves from the general to a particular.

Imaginary audience is an identifier of adolescent egocentrism along with personal fable. The individual believes that others are keeping an eye on them all the time. They have this faith that people are watching and also judging their behavior and activities regularly.

Self-awareness is incorrect as in this, the individual evaluates his emotions, thoughts, and actions to make improvements. It is self-analysis to focus on improving values and behavior and understanding the opinions of others about themselves. This adolescent is aggressive and is showing features suggestive of a personal fable.

Communicative intent is correct because the child only repeats words (his toy’s name) when he wants to give an assertive response. He uses a different word (Walmart) when he wants to give a dismissive or negative response. Echolalia is a communication tool that is a highly important step in establishing a connection and developing language skills in autistic children. The communicative intent of the child by using echolalia is apparent in this case as he is responsive, engaged, and aware of the present environment while maintaining a stable emotional state.

Response to distress is incorrect because the child appears relaxed and happy. Echolalia is common in children with autism spectrum disorders, and it can occur during highly stressful situations. However, in this scenario, the child does not appear distressed, frightened, or disturbed; therefore, his echolalia cannot be attributed to negative emotions.

Support concentration is incorrect because the child does not appear to be concentrating on anything. The vignette presents an interview between the patient and the clinician, and the child uses echolalia as a communicative intent. In many instances, the autistic child may repeat words when attempting an activity that requires concentration and attention. But that is not the case for this child as he is not performing an activity requiring support for concentration or attention.

Imaginary play is incorrect because the child is engaged and responsive to the clinician’s questions. Children using echolalia in imaginary play do not respond by verbal or nonverbal cues when they’re addressed, as they are too invested in imaginary play. The child is responsive and present with the clinician, which demonstrates a positive step in managing language deficits.

No purpose is incorrect because the child’s responses were purposeful and communicative. He only said words in response to a question, and his body language and facial expressions served as nonverbal cues to his responses. Echolalia does not serve any purpose in people or children who are mentally disabled or unable to understand the question. This child has enthusiastically used echolalia as a communicative tool, demonstrating progress in improving social and language skills.

Attention deficit hyperactivity disorder (ADHD) is correct because the girl fulfills the DSM-5 criteria of hyperactivity subtype of ADHD. She was noticed to fidget and squirm in her seat, is unable to sit still, prefers running about and climbing the majority of the time, talks excessively, interrupts frequently, is difficult to discipline, and remains hyperactive. It is important to establish whether ADHD exists with a mood disorder or the symptoms are simply due to mania because intervention would be based on the final diagnosis. Literature reports that ADHD symptoms are common in childhood bipolar disorder, yet a thorough evaluation is required to reach a definite diagnosis.

Autism spectrum disorder (ASD) is incorrect because the child does not exhibit any communication or speech deficits, repetitive behavior, or excessive adherence to routines. Children with ASD usually present with delayed speech, inability to form normal relationships, and restricted stereotypical behavior that is fixated with routines and the use of familiar toys/objects. This girl has mood swings and hyperactivity without any evidence of social or communicative deficit.

Conduct disorder is incorrect because the girl’s disruptive behavior is episodic and only flares with mood swings. Children with conduct disorder are constantly combative, aggressive, and defiant, with a history of serious violations of rules, including deceitfulness, theft, and argumentative persona. This girl has some characteristics of ODD, but these traits come and go depending on her mood. Moreover, she has friends who get along with her, and she did not exhibit any combative behavior in the clinic despite wishing to leave.

Obsessive-compulsive disorder (OCD) is incorrect because the vignette does not describe ritualistic obsessive-compulsive behavior. Children with OCD have various features depending on their personality. Still, it is easy to pick up ritualistic behaviors like lining up toys, following a strict routine, repeating tasks to abate anxiety, and sorting clothes, toys, and objects in a certain way. This girl does not exhibit any characteristic signs of OCD at this time.

Post-traumatic stress disorder (PTSD) is incorrect because the patient does not exhibit sadness, fear, and nightmares, or sleep problems that are common in PTSD. There may be anger outbursts and mood swings in PTSD. Still, an obvious traumatic experience is usually known, and the symptoms are associated with triggering the memory of that event. This girl’s mother committed suicide when she was still a neonate, so the effects of that information may be traumatic. However, presently, her symptoms and disposition favor ADHD and mood disorder over full-blown PTSD.

FMR1 gene is correct because fragile X syndrome is a strong possibility given the developmental history and physical features. It is important to exclude genetic disorders when the child has distinctive phenotypic features and positive family history of mental retardation. Children with fragile X syndrome have mutations in the FMR1 gene. The American College of Medical Genetics recommends testing for fragile X, irrespective of family history, for all children with mental retardation and autistic features of unknown etiology.

TSC1 and TSC2 genes is incorrect because the boy does not have features of tuberous sclerosis. Mutations in TSC1 and TSC2 genes are found in patients with tuberous sclerosis, and the key diagnostic triad comprises epileptic seizures, facial lesions, and mental retardation. This boy has a developmental delay, speech and social deficits with peculiar physical findings that are not suggestive of tuberous sclerosis.

Dystrophin-encoding DMD gene is incorrect because the boy does not have muscular dystrophy or progressive muscle weakness indicative of Duchene muscular dystrophy. The mutations in the dystrophin-encoding DMD gene are found in Duchene muscular dystrophy, in which children have normal neurocognitive and social development, but there is progressive muscular weakness.

MECP2 gene is incorrect because it is a nonspecific gene that can be mutated in various disorders like Rett syndrome, OCD, global developmental delay, and ADHD. Rett syndrome is one of the more specifically linked disorders to MECP2 mutations in mentally disabled children. However, this child does not exhibit classical wriggling hand movements or an abnormal gait in Rett syndrome. But still, fragile X syndrome can closely mimic Rett syndrome in a child as both syndromes lead to developmental delays, fine motor deficits, and autism-like behavioral problems. A meticulous focus on developmental and family history is required to differentiate between the two. Conclusively, genetic testing is a definitive way of reaching a final diagnosis.

NF1 gene is incorrect because NF1 mutations are found in neurofibromatosis syndromes, and there are no cutaneous, neurological, or eye neurofibromas in this child. Some children with epilepsy and brain tumors may have neurocognitive deficits and mental retardation, but that is not the case for this child who does not have any suspicious tumors, café au lait spots, or space-occupying brain lesions indicative of neurofibromatosis.

Dynamic assessment is correct because it evaluates the child’s learning ability without linguistic and cultural bias. Dynamic assessment is the most reliable and adaptable tool that helps differentiate a language different from a disorder by the commonly utilized test-teach-retest method. It also determines the type of support, cues, and material that the child requires to learn the language and overcome the barriers in communication. However, dynamic assessment is one aspect of assessing cultural and linguistic differences, and the clinician requires further alternative measures, standardized tests, and detailed history to understand the child’s speech and cognitive abilities.

Translated norm-based assessment is incorrect because these standardized tests do not translate reliably to evaluate a language disorder. Norm-based assessment comprises standardized tests to compare the child with other same-age children to identify differences. Although translating these tests into the native language of a child is a viable option, the result remains unreliable given the inconsistency in translation and interpretation by the child.

Decontextualized criterion-referenced assessment is incorrect because it does not differentiate linguistic difference and disorder. Criterion-referenced assessment helps the clinician to examine specific behaviors children adopt to communicate by undertaking individualized tasks. A decontextualized setting evaluates how a child comprehends language without the presence of other non-linguistic cues.

Children’s speech intelligibility measure is incorrect because it is a tool for examining the intelligibility of a child’s speech who is as young as a pre-schooler or pre-literate. Speech intelligibility measures do not help differentiate linguistic differences; instead, these measures are preferable for children with dysarthria to evaluate the severity of speech disorder and potentially distinguish children with a speech disability.

Contextualized criterion-referenced assessment is incorrect because it examines the factors involved in communication without helping differentiate between language difference and disorder. Criterion-referenced assessment is carried out in a contextualized setting if the child is provided with additional non-linguistic cues to perform a task that assesses their ability to communicate effectively.

Reduced hippocampal volume is correct because studies demonstrate that the hippocampus is a predominant structure that is atrophied bilaterally in patients of schizophrenia. The atrophy of the hippocampus causes the worsening of the negative symptoms of schizophrenia by impairing verbal memory and emotional expression and diminishing pleasure. Therefore, reduction in hippocampal volume indirectly affects the negative symptoms of schizophrenia. It is also prominent finding on neuroimaging when the total intracranial volume is adjusted and volumetric segmentation and measurement is performed on the MR imaging of the brain.

Ventricular shrinkage is incorrect because there is cerebral atrophy in schizophrenia that leads to ventricular enlargement. Ventricular enlargement is a strikingly common finding in adult or child-onset schizophrenia and is correlated to diffuse reduction in the cerebral volume of both hemispheres.

Frontotemporal atrophy is incorrect because it occurs in tauopathy like Pick’s disease and results in dementia in elderly individuals. Although frontal and temporal lobes can be atrophied in schizophrenia, they are not involved in isolation, and the shrinkage occurs as a result of gross cerebral atrophy.

Cerebellar atrophy is incorrect because it is an inconsistent finding in schizophrenia, and not all patients have reduced cerebellar volume. Cerebellar atrophy would lead to clinical difficulties in motor tasks and coordination. It is not the most striking or common feature of schizophrenia.

Cerebellar hypertrophy is incorrect because it does not occur in psychiatric disorders, specifically schizophrenia. Cerebellar hypertrophy occurs in dysplastic disorders of the brain parenchyma like Lhermitte-Duclos or other tumorous malformations of the cerebellum.

Teacher evaluations is the correct answer because the diagnosis of attention-deficit hyperactivity disorder requires evidence of inattentive and/or hyperactive/impulsive symptoms for 6 months in 2 settings (home, school, after-school program). Teacher evaluations can assist in diagnosis.

Brain imaging and EEG is incorrect because they are not performed routinely in the work-up of ADHD in the absence of other neurological symptoms. They would not be indicated in this patient with no other medical history and a normal physical examination.

Hearing test is incorrect because it is not routinely performed in the initial evaluation of ADHD, and hearing impairment would have likely been identified by this age. However, a hearing test should be performed if coexisting hearing impairment is suspected.

Speech and language evaluation is incorrect because it would be warranted if the patient had problems with speech articulation/production or his language development was delayed.

Toxicology screening is incorrect because it is not routinely performed in the assessment of ADHD in this age group. It is less likely to be helpful in the assessment of this patient who lacks any history pointing to medical illness or substance use.

Oppositional defiant disorder (ODD) is the correct answer because anger, irritable mood, and defiant behavior toward authority figures and peers without serious violation of social norms, lasting 6 months point towards oppositional defiant disorder diagnosis. Individuals with ODD are negatively impacted in numerous areas important for normal functioning (social, educational), and the hostility they express is toward individuals within their immediate social circle (family members, peers, teachers), which is seen in this patient’s behavior toward her teachers and classmates.

Bipolar Affective Disorder is not the most likely diagnosis as there are no reports of grandiosity or consistent symptoms of depression. Additionally, the irritability seen with Bipolar youth is generally episodic. Here, the teen seems consistently defiant, demanding when not getting her way.

Antisocial personality disorder is incorrect because patients with antisocial personality disorder are remorselessly impulsive, violent, and deceitful. Such behavior is not present in this patient. Moreover, a diagnosis of antisocial personality disorder cannot be made until the person is 18 years of age.

Attention-deficit hyperactivity disorder is incorrect because, unlike this child who defiantly refuses to answer questions, children with ADHD have difficulties controlling their impulses to talk and tend to answer out of turn. Moreover, temper tantrums and insulting behavior are not typical features of ADHD alone.

Normal adolescent behavior is incorrect. Although mildly disruptive behavior and occasional temper tantrums can be a part of normal adolescent development, such behavior is considered pathological when it is frequent, persistent, and impairs the functioning of the individual and of others (peers, teachers, parents).

Tourette syndrome is the correct answer because it is characterized by simple and complex motor tics and involuntary vocalizations (including cough). A minority of individuals with the condition utter obscenities or perform obscene gestures.

Absence seizures is incorrect because they are very brief generalized seizures in children that cause impaired consciousness. They may occur hundreds of times a day and present as brief staring spells.

Attention deficit hyperactivity disorder is incorrect because although this patient is described as inattentive and fidgety, there is insufficient evidence for this diagnosis.

Autism spectrum disorder is incorrect because it is a neurodevelopmental condition characterized by impaired social and verbal communication, stereotyped or repetitive behaviors, and restricted interests. Stereotyped behaviors (hand flapping) occur but are not usually mistaken for tics.

Chronic tic disorder is incorrect because it involves one or more motor or verbal tics (but not both) for one year. This patient has both motor and vocal tics, with a history that supports both being present, likely, for more than 1 year as well.

Polysomnography is the correct answer because narcolepsy should be considered in a young patient with excessive daytime sleep, especially if the patient also experiences falling asleep suddenly at inappropriate times, hypnagogic hallucinations, or cataplexy. Polysomnography is the gold standard in diagnosing narcolepsy.

CT scan of the head is incorrect because it can be useful for identifying signs of increased intracranial pressure (ICP) that can cause excessive daytime sleep. However, this patient lacks other features of increased ICP (headaches, nausea/vomiting, gait disturbances).

Electroencephalography is incorrect because it is used to diagnose seizures. This patient’s excessive daytime sleepiness and hypnagogic hallucinations are unlikely to represent seizures.

TSH levels is incorrect because it is a hormone involved in thyroid synthesis and can be key to diagnosing thyroid disease. This patient has stable vital signs and BMI and no other symptoms to suggest thyroid disease.

Sleep diary is incorrect because it can document a patient’s sleep pattern over several weeks and is helpful for evaluating circadian rhythm disorders. This patient has a delayed sleep phase (late to bed, late to rise), which is common at his age. Besides, he seems to get an adequate amount of sleep (at least 7 hours nightly). Again, the best next step to give a firm diagnosis is a polysomnogram.

Genetic testing for an x-linked disorder is correct because every child with intellectual disability should be screened for genetic disorders, e.g., fragile X syndrome, Rhett syndrome, or tuberous sclerosis. The presence of typical physical appearance, progressive hyperactivity, developmental delays, and intellectual disability all favor a genetic syndrome. The most common neurodevelopmental disorder leading to intellectual disability in children is fragile X syndrome. It is inherited from the X-chromosome, but family history is not necessary, as mutations can be sporadic.

Blood work for a thyroid disorder is incorrect because the vignette does not present clinical features of a hypo or hyperthyroid child. Even though there could be some degree of hyperactivity in hyperthyroidism, the physical appearance and mental retardation do not favor it. Hyperthyroidism is relatively rare in children and presents with restlessness, diarrhea, palpitations, weight loss despite a good appetite, sweating, and emotionally labile children. Hyperthyroidism is considered when other clinical findings are strongly suggestive.

Brain imaging for structural lesions is incorrect because children with structural brain lesions commonly present with epileptic seizures and movement disorders. Mental retardation is also a feature of early childhood brain lesions like tuberous sclerosis and neurofibromatosis. Still, this child does exhibit any specific feature that hints that brain imaging would be diagnostic of the disorder underlying his intellectual disability and hyperactivity.

Urine toxicology is incorrect because the child’s problems do not indicate substance abuse considering that the symptoms started from infancy. Hyperactivity and mental retardation are risk factors for substance abuse. Given the positive family history of drug use, it dramatically increases the patient’s risk of using drugs in late childhood and early adolescence. However, presently there are no specific findings of acute drug intoxication in this child that warrants urine toxicology.

Electroencephalography (EEG) is incorrect because the child does not have seizures or epileptic episodes that require an EEG. The utility of EEG in patients without overt tonic-clonic seizures is in diagnosing subtle or silent epilepsies like absence seizures. An electroencephalogram would not help diagnose the underlying cause of this child’s intellectual disability.

Low resting heart rate is correct because studies found a statistically significant association between aggression and antisocial traits and low resting heart rate. The phenomenon is hypothesized to occur because a low resting heart rate leads to autonomic under-arousal that causes seeking stimulation via violent and defiant acts. Low arousal also leads to poor control states and emotional dysregulation in children, causing a lack of fear and poor conditioning to stimuli that could be potentially threatening, e.g., punishment. These children cannot socialize steadily; instead, they prefer to break the rules, cause destruction, and respond with aggression and defiance.

High resting heart rate is incorrect because antisocial behavior and conduct disorders are not associated with resting tachycardia in children. A high resting heart rate is usually found in hyperdynamic states like severe anemia, thyrotoxicosis, heart failure, or infections.

High resting blood pressure is incorrect because fluctuations of blood pressure outside of the normal range do not occur in conduct disorders unless coexistent due to other comorbidities. High resting blood pressure is always pathological in both adults and children and indicates an organic disease. There is no link between blood pressure to antisocial behavior in children.

Low resting blood pressure is incorrect because blood pressure changes are not observed in children with behavioral problems. Low resting blood pressure can be normal or abnormal depending on the baseline reading and does not correlate with conduct disorders.

Low sleeping respiratory rate is incorrect because no concrete data is available from studies regarding respiratory patterns in conduct disorders or antisocial traits. However, in animal models, anxiety, aggression, and rage are positively correlated with high respiratory rates. This cannot be reiterated for human children, and studies are lacking in this domain.

Provisional tic disorder is correct. This patient’s symptoms of involuntary blinking, shrugging, winking, and grunting, and the development of symptoms before the age of 18 years give a clue to the diagnosis of tic disorder. Tic disorder is characterized as provisional when the duration of the disorder is less than one year, symptoms are ongoing, and single or multiple motor or vocal tics or both occur many times a day on most days. The absence of drug and medical history further confirms the diagnosis.

Chronic motor tic disorder is incorrect. Chronic motor tics are characterized by motor tics alone, and the duration of symptoms must be at least 12 months.

Chronic vocal tic disorder is incorrect. Chronic vocal tics are characterized by vocal tics alone, and the duration of symptoms must be at least 12 months.

Tourette syndrome is incorrect. Tourette syndrome is another name for combined vocal and motor multiple tic disorder. It is characterized by multiple motor tics and one or more vocal tics that have been present for more than a year.

Cocaine-induced tic disorder is incorrect and highly unlikely in that the patient is only 10 and has no significant past drug use history.

Beneficence is correct because this psychiatrist’s main objective is for the well-being of his client. This patient presents with a severe eating disorder that is harmful to his health. When physicians are aware of their limitations, they should bring in other resources (i.e. outside consultation) to better treat the needs of the patient.

Respect for the law is incorrect because it would involve the psychiatrist breaching confidential information to the police and appropriate authorities to prevent damage or protect someone’s life.

Veracity is incorrect because it involves being honest and telling the truth to the patients and is related to the principle of autonomy.

Fidelity is incorrect because it involves honesty, honoring commitments, and faithfulness/ loyalty. Fidelity is important as patients should be able to trust their physician for the therapeutic relationship to flourish.

Autonomy is incorrect because it is self-determination or the right of competent individuals to make informed choices about their treatment.

Notify Child Protective Services (CPS) is the correct option because this is done in cases of suspected child abuse, which could include bruising, multiple fractures, and burn injuries. The presence of symmetrical, sharply bullous lesions on this child’s arms and legs are highly suggestive of scald burns as a result of intentional immersion in a hot liquid.

Talk to the stepmother individually is incorrect because this child’s skin findings most likely resulted from trauma caused by immersion of her hands and lower legs in hot liquid. However, the stepmother denies a recent history of trauma, which should raise suspicion that the patient’s stepmother is hiding the actual story. Moreover, talking to the stepmother individually could lead to her avoiding further physician contact and ultimately place the child at risk of further abuse.

Schedule a follow-up examination for further evaluation is incorrect because it is not indicated in cases of suspected child abuse. Ensuring the child’s safety is the preferred step and should take precedence.

Perform a forensic interview of the child is incorrect because, at this stage, ensuring the child’s safety is the most appropriate next step in management and should, therefore, take precedence.

Obtain a biopsy specimen of the skin lesions for histopathological examination is incorrect because the diagnosis of immersion burns does not require histopathological examination, as it can be made clinically.

Determining whether the patient needs language assistance is the correct option because this patient’s immigrant background and difficulty in communicating with the physician raise concerns for limited English proficiency (LEP). To avoid discrimination and miscommunication in treating this patient, it is mandatory to provide professional interpreter services if needed. If the patient’s condition becomes medically emergent (i.e. physically assaultive, seizures, etc.) then immediately treating those issues takes precedence.

Calling family members is incorrect because this patient emancipated herself, and it would also be considered a breach of confidentiality.

Assessing the patient’s religious beliefs is incorrect because it is not the appropriate initial action. Addressing a potential language barrier takes precedence.

Use her friend as an interpreter is not preferred due to possible partiality and struggle in conveying accurate medical information. Therefore, a trained language interpreter’s assistance must be used.

Refer her to another facility with providers who speak Spanish is incorrect because she must be evaluated and treated there in the emergency room first.

Immediately disclose the error to the mother with an apology is the correct option because physicians are ethically obligated, according to the principle of veracity, to be honest and truthful to their patients. It is preferable to disclose the error in a timely manner, regardless of whether harm has occurred or not.

Discuss the matter with nursing and pharmacy staff is incorrect because this would be the first step only if there is doubt about whether an error occurred. In this case, it is confirmed that the medication error occurred, so this is not the initial course of action.

Arrange for the hospital to not charge for an extra stay is incorrect because although it would be an appropriate measure and benefit the patient, this is not an appropriate alternative to an apology for the medical error.

Do not disclose the error as the patient was not harmed is incorrect because it would be unethical and unprofessional.

Wait until the patient is alert and then disclose the error to him is incorrect because his altered mental status would prevent him from understanding the nature of the error. It is preferable to disclose the error immediately to his mother than to wait for him to recover.

Inform the nurse that no information can be divulged is the correct option because the nurse is not directly involved in this patient’s care, and in accordance with the Health Insurance Portability and Accountability Act (HIPAA), it is unethical to disclose privileged health information to third parties without the patient’s consent.

Tell the nurse the patient’s case file number so she can look it up herself is incorrect because looking into a patient’s medical record for reasons unrelated to direct medical care violates HIPAA and is never appropriate.

Tell the nurse that he cannot tell her the diagnosis but that the patient was treated with naloxone is incorrect because the release of even partial information about a patient to another individual qualifies as a breach of patient confidentiality.

Ask the nurse to meet in his office so they can discuss the patient in private is incorrect because revealing information at this time, even in a private setting, is a violation of HIPAA.

Tell the nurse to ask the patient herself is incorrect because allowing someone to inquire about personal health directly from the patient without his/her consent is unethical.

Part C is correct because this part is concerned with the provision of early intervention to infants and toddlers (from birth to 3 years of age).

Part A is incorrect because this part is concerned with general provisions of the law.

Part B is incorrect because this part is aimed at providing early interventional support to children with disabilities aged 3 years to 21 years.

Part D is incorrect because this part is concerned with national support programs aimed at personnel development and the improvement of federal systems.

Part E is incorrect. IDEA is comprised of 4 sections, parts A-D. There is no part E of the IDEA program.

Supportive-expressive therapy is the correct option. This patient has presented with signs and symptoms consistent with grief at the loss of her parent and is at high risk of developing complicated grief. Supportive-expressive therapy results in guided mourning. It helps accomplish fundamental tasks of mourning which include accepting the loss, working through grief, adjusting to a new altered environment, and establishing positive and useful memories of the loved one for future reference. Sharing of grief will result in better functional outcomes with less incidence of developing complicated grief.

Antidepressants is incorrect because they are indicated when grief is combined with depressive symptoms, panic disorder, or severe adjustment disorder or grief becomes complicated per DSM and the patient fails psychotherapy.

Benzodiazepines is incorrect because they may cause dependence and tachyphylaxis, and are not recommended.

Complicated grief treatment is incorrect because it is reserved for patients who have persistent symptoms 6 months after losing a loved one. As her mother has recently passed away, it is a less likely possibility.

Risperidone is incorrect because it is given to patients who develop manic or hypomanic symptoms after losing a loved one or become actively psychotic.

Ask her to try to change her circumstances is the correct option because this strategy will get in the way of developing resilience. This patient’s circumstances are unlikely to change in the foreseeable future, and she has to navigate them and accept the change positively. Therefore, advising her to change her circumstances is going to be harmful to this patient.

Offer expertise and control is incorrect because counselors must be supportive and find ways to build resilience in this girl.

Family education is an incorrect option because resilient children have a close bonding with their parents. Educating this girl’s mother is important to encourage a supportive relationship by providing emotional guidance and planning ahead.

Encourage self-efficacy is incorrect because it is a vital trait to promoting resilience in children. This girl is contributing to the house and feels underappreciated, and misses hanging out with friends. Encouraging her mother about defining family duties and letting her daughter find time for social activities is important to develop resilience.

Care coordination is incorrect because care coordinators can act by helping this girl and her mother out by communicating with the school and other agencies.

Alcohol Use Disorders Identification Test (AUDIT) is the correct response as it is a widely used screening tool consisting of ten questions that can be self-administered or read aloud. Higher scores indicate hazardous or harmful alcohol consumption. It has been used successfully in adolescents and youth aged 14-18 years.

T-ACE is incorrect because it is most often used to assess drinking patterns in pregnant women.

General health questionnaire is incorrect because it is used to identify short-term anxiety, depression, somatic symptoms, and social dysfunction.

Revised conflict tactics scale (CTS2) is incorrect because it is used to screen lifetime interpersonal violence in women.

Vineland adaptive behavior scales is incorrect because it is used to assess adaptive skills in individuals with developmental delays

Selective prevention is the correct option because it is reserved for a group of families or children whose characteristics place them at a higher risk of developing problems later in life. Since these children have suffered a stress-related event but are currently asymptomatic, they fall under the umbrella of selective prevention. Appropriate management will reduce the risk of complicated grief and post-traumatic stress disorder in these children.

Indicated prevention is incorrect because it’s indicated for children who have already developed signs and symptoms of the disease. As these children are asymptomatic, it is a less likely possibility.

Universal prevention is an incorrect option because it will target all children instead of children who have suffered stress and loss.

Specific prevention is incorrect because it targets a group of diseases and complements health promotion goals.

Secondary prevention is incorrect because it tries to restore health by arresting the disease progression and treating the disease before irreversible damage occurs.

Multidisciplinary professional and parental support is correct because anti-bullying programs should be implemented across the entire school range. A multidisciplinary approach that includes parental involvement and appropriate support by mental health professionals is the standard therapy that has consistently shown good results in decreasing bullying. A classroom-based strategy that targets behaviors, attitudes, and beliefs is also important and will improve the teacher-student relationship.

Peer mediation and peer mentoring for the bullied children is incorrect because they have not been shown to be effective in this clinical situation.

Disciplinary action against the bullies is incorrect because it has not proven to be fruitful. Instead, a school-based policy that values all students should be implemented.

Increased supervision on the playground is incorrect because the program should be implemented across all ages and not just for younger children.

Coping skills therapy is incorrect because it has been tried with moderate success in patients at risk of developing post-traumatic stress disorder.

Social awareness is correct because it is the capacity to be aware of the emotional perspectives of different people and to consider their points of view in a particular situation. In this case, the boy is able to identify the emotional turmoil his mother is experiencing and demonstrates empathy and compassion.

Self-awareness is incorrect because it is the ability to understand one’s emotions and behaviors and link them to personal growth by identifying self-strengths and limitations.

Self-management is incorrect because it is the ability to set goals and plan to reach a goal.

Responsible decision-making is incorrect because it is the ability to make sound and fair decisions based on logical thinking and critical analysis of diverse social situations.

Relationship skills is incorrect because it is the ability to build and maintain healthy and supportive relationships by effectively cooperating and communicating between diverse social groups.

Pseudo Bartter syndrome and low birth weight is correct because electrolyte and an acid-base imbalance are expected to arise in babies of patients with severe eating disorders, characterized by hypokalemia, hypochloremic metabolic alkalosis, hyponatremia, and normal blood pressure with increased levels of renin and aldosterone. This can be associated with intrauterine growth retardation, which is a common manifestation found in babies of anorexic mothers.

Cardiac anomalies is incorrect because these abnormalities are more common in fetuses exposed to lithium.

Cleft lip/palate is incorrect because this abnormality is more associated with mothers taking valproic acid and carbamazepine.

Post-term baby is incorrect because patients diagnosed with anorexia are at a higher risk of giving birth to pre-term babies and having premature delivery or miscarriages.

Chromosomal abnormalities is incorrect because these usually do not arise in the fetus of patients having anorexia nervosa.