A 5-year-old girl is brought to the physician because her mother has found her to be inattentive at home and has received multiple complaints from her teachers at school. She does not complete her assignments and does not listen to her teachers' instructions. She refuses to talk to her parents or peers. Her mother says, “She ignores everything I say to her!” She prefers playing alone, and her mother reports that she likes playing with 5 red toy cars, repeatedly arranging them in a straight line. She avoids eye contact with her mother and the physician throughout the visit. Physical and neurological examination shows no abnormalities. Which of the following is the most likely diagnosis?

Attention deficit hyperactivity disorder

A mother brings her 3-year-old son to the doctor because she is worried that he might be harming himself by constantly banging his head on the wall. He has been exhibiting this behavior for a few months. She is also worried because he has started to speak less than he used to and does not respond when his name is called. He seems aloof during playtime with other children and seems to have lost interest in most of his toys. What is the most likely diagnosis?

Attention deficit hyperactivity disorder

A 16-year-old girl comes to the physician for a regular health visit. She feels healthy. She lives with her parents at home. She says that the relationship with her parents has been strained lately because they ""do not approve"" of her new boyfriend. She recently became sexually active with her boyfriend and requests a prescription for an oral contraception. She does not want her parents to know. She smokes half-a-pack of cigarettes per day and does not drink alcohol. She appears well-nourished. Physical examination shows no abnormalities. Urine pregnancy test is negative. Which of the following is the most appropriate next step in management?

Discuss all effective contraceptive options

Recommend an oral contraceptive pill

Inform patient that her smoking history disqualifies her for oral contraceptives

Ask patient to obtain parental consent before discussing any contraceptive options

A 17-year-old white female with a history of depression is brought to your office by her parents because they are concerned that she is acting differently. She is quiet and denies any changes in her personality or drug use. After the parents step out so that you can speak alone, she begins crying. She states that school has been very difficult and has been very depressed for the past 2 months. She feels a lot of pressure from her parents and coaches and says she cannot handle it anymore. She says that she has been cutting her wrists for the past week and is planning to commit suicide. She instantly regrets telling you and begs you not to tell her parents. What is the most appropriate course of action?

Explain to her that she will have to be hospitalized as she is an acute threat to herself

Prescribe an anti-depressant medication and allow her to return home

Tell her parents about the situation and allow them to handle it as a family

Prescribe an anti-psychotic medication

A 3-year-old boy is brought in by his mother because she is concerned that he has been “acting differently recently”. She says he no longer seems interested in playing with his friends from preschool, and she has noticed that he has stopped making eye contact with others. In addition, she says he flaps his hands when excited or angry and only seems to enjoy playing with objects that he can place in rows or rigid patterns. Despite these behaviors, he is meeting his language goals for his age (single word use). The patient has no significant past medical history. He is at the 90th percentile for height and weight for his age. He is afebrile and his vital signs are within normal limits. A physical examination is unremarkable. Which of the following is the most likely diagnosis in this patient?

Pervasive developmental disorder, not otherwise specified

Childhood disintegrative disorder

A 16-year-old boy comes to the physician for the evaluation of fatigue over the past month. He reports that his energy levels are low and that he spends most of his time in his room. He also states that he is not in the mood for meeting friends. He used to enjoy playing soccer and going to the shooting range with his father, but recently stopped showing interest in these activities. He has been having difficulties at school due to concentration problems. His appetite is low. He has problems falling asleep. He states that he has thought about ending his life, but he has no specific plan. He lives with his parents, who frequently fight due to financial problems. He does not smoke. He drinks 2–3 cans of beer on the weekends. He does not use illicit drugs. He takes no medications. His vital signs are within normal limits. On mental status examination, he is oriented to person, place, and time. Physical examination shows no abnormalities. In addition to the administration of an appropriate medication, which of the following is the most appropriate next step in management?

Instruct parents to remove guns from the house

Contact child protective services

An 11-year-old boy is brought to a pediatrician by his parents with the complaint of progressive behavioral problems for the last 2 years. His parents report that he always looks restless at home and is never quiet. His school teachers frequently complain that he cannot remain seated for long during class, often leaving his seat to move around the classroom. A detailed history of his symptoms suggests a diagnosis of attention-deficit/hyperactivity disorder. The parents report that he has taken advantage of behavioral counseling several times without improvement. The pediatrician considers pharmacotherapy and plans to start methylphenidate at a low dose, followed by regular follow-up. Based on the side effect profile of the medication, which of the following components of the patient’s medical history should the pediatrician obtain before starting the drug?

Past history of Kawasaki disease

Past history of recurrent wheezing

Past history of idiopathic thrombocytopenic purpura

Past history of recurrent fractures

Past history of Guillain-Barré syndrome

A 4-year-old boy presents with language delay, toe-walking, hand-flapping, and intense interest in trains. He makes poor eye contact but occasionally engages in joint attention with his mother when looking at trains. He has sensory sensitivities to loud noises. He can identify all letters and numbers but cannot have reciprocal conversations. His Childhood Autism Rating Scale (CARS) score is borderline. His parents request your opinion on diagnosis and intervention priorities given diagnostic uncertainty and limited early intervention resources in their area.

Presume autism spectrum disorder and implement evidence-based early interventions while monitoring

Diagnose autism spectrum disorder and begin comprehensive ABA therapy immediately

Diagnose language disorder and focus resources on communication training

Refer to genetics for testing before committing to diagnosis or intervention

Delay diagnosis pending further developmental assessment and prioritize speech therapy

A 15-year-old girl with ADHD-predominantly inattentive type has tried methylphenidate, amphetamine salts, and atomoxetine with partial response or intolerable side effects. She has comorbid anxiety disorder and mild depression. She is motivated for treatment and has good family support. Her psychiatrist considers guanfacine as next-line therapy. Evaluate the appropriateness of this choice given her clinical profile.

Appropriate - alpha-2 agonist may help both ADHD and anxiety

Appropriate - guanfacine is superior to stimulants in adolescent females

Inappropriate - should try combination stimulant therapy first

Inappropriate - should address anxiety and depression first before ADHD

Inappropriate - guanfacine is only for hyperactive-impulsive ADHD symptoms

Transition to adult care for USMLE Step 2 CK: High-Yield Psychiatry Lessons

The Transition Cliff - Why It Matters

Definition: Abrupt cessation of coordinated pediatric, educational, & social support services upon reaching the age of majority (18-21 years).
- Education: Loss of Individuals with Disabilities Education Act (IDEA) protections & Individualized Education Programs (IEPs).
- Healthcare: Forced shift from experienced pediatric specialists to adult providers often untrained in developmental disorders.
- Support: Discontinuation of family-centered care models & school-based social structures.

Healthcare barriers for individuals with ASD across lifespan

Consequences:
- ↓ Medication adherence & treatment engagement.
- ↑ Rates of unemployment, underemployment, & justice system involvement.
- ↑ Comorbid anxiety, depression, & substance use disorders.

⭐ A significant number of young adults with ASD lose access to services after leaving high school, contributing to poor long-term outcomes in employment and independent living.

ADHD Transition - Shifting Focus

Pediatric → Adult Care Shift: Abrupt change from a family-centered, structured model (scaffolding) to a patient-autonomy model (self-advocacy).
- Pediatric Focus: Primarily academic (IEPs, 504 plans), behavioral targets, parental guidance.
- Adult Focus: Occupational/interpersonal function, independent living skills, self-management.
Common Transition Failures:
- Medication Management: ↑ risk of non-adherence, diversion, and misuse. Crucial to screen for comorbid substance use.
- Psychosocial Support: Loss of structured school supports. Shift to navigating workplace accommodations (ADA) and vocational rehabilitation.

⭐ A significant number of young adults with ADHD are lost to follow-up during the transition. Less than 50% continue to receive care into their 20s, leading to untreated comorbidities and functional impairment.

Objective: Equip autistic young adults with structured guides (scripts) for navigating new adult social interactions, reducing anxiety & cognitive load.
Core Areas for Scripting:
- Healthcare: Self-advocacy with providers, scheduling appointments, describing symptoms clearly.
- Vocational: Job interviews (e.g., "Tell me about yourself"), workplace etiquette, requesting accommodations.
- Independent Living: Interacting with landlords, banking, navigating public services.
- Relationships: Initiating conversations, understanding social cues in dating, setting boundaries.

⭐ Transition to adult services often unmasks significant deficits in adaptive functioning and self-advocacy previously supported by family and school structures.

💡 Use the "Situation-Options-Consequences-Choices-Strategies-Simulation" (SOCCSS) model to co-create scripts with the individual.

Transition Models - The Handoff Playbook

A structured, gradual handoff from pediatric to adult care prevents the "care cliff" often seen at age 18 or 21.

Key Elements (The "4 P's"):
- Policy: Establish a formal transition policy, ideally starting discussions by age 14.
- Plan: Develop a written, portable medical summary and an emergency care plan.
- Provider Coordination: Use a transition coordinator or integrated care models where pediatric and adult teams overlap and communicate.
- Patient Preparation: Build self-advocacy skills; educate on consent, insurance, and navigating the adult system.

⭐ High-Yield: Lack of a planned transition is a primary reason for treatment discontinuation in young adults with ADHD/ASD, leading to increased risk of psychiatric hospitalization and substance use.

High-Yield Points - ⚡ Biggest Takeaways

A structured transition plan is vital to prevent gaps in care and ensure medication continuity for young adults.

Routinely screen for common comorbidities like anxiety, depression, and substance use disorders.

Management focus shifts from academics to occupational, social, and independent living challenges.

Re-evaluate medication regimens for appropriateness and side effects in the adult context.

Address legal changes at age 18, including guardianship and healthcare decision-making.

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