Child and Adolescent Psychiatry Practice Questions

Q: Which of the following conditions is seen predominantly in females?

Rett syndrome. **Explanation:** **Rett Syndrome (Option B)** is the correct answer because it is an X-linked dominant neurodevelopmental disorder caused by a mutation in the **MECP2 gene**. It is seen almost exclusively in **females**. In males, the mutation is typically lethal in utero or results in severe neonatal encephalopathy, as they lack a second X chromosome to compensate for the defect. **Clinical Features of Rett Syndrome:** * Initial normal development for the first 6–18 months. * Subsequent regression of language and motor skills. * **Pathognomonic sign:** Purposeful hand movements are replaced by repetitive, stereotypic **"hand-wringing"** or "hand-washing" motions. * Deceleration of head growth (acquired microcephaly). **Analysis of Incorrect Options:** * **Autism (Option A) & Asperger Syndrome (Option C):** Both are part of the Autism Spectrum Disorders (ASD). ASD shows a strong **male predominance**, with a male-to-female ratio of approximately 4:1. * **Cornelia de Lange Syndrome (Option D):** This is a genetic multisystem malformation syndrome characterized by facial dysmorphism (synophrys/monobrow), limb defects, and intellectual disability. It affects males and females **equally**. **High-Yield Clinical Pearls for NEET-PG:** * **MECP2 mutation** on the X chromosome is the hallmark of Rett Syndrome. * It was previously classified under Pervasive Developmental Disorders (PDD) in DSM-IV but is now considered a distinct genetic neurological entity. * **Differential Diagnosis:** If a child presents with "hand-wringing" and "regression of milestones" after a period of normalcy, always suspect Rett Syndrome.

Q: An IQ score between 70-75 denotes which of the following intellectual functioning levels?

Borderline intellectual functioning. **Explanation:** The classification of intellectual functioning is primarily based on the Intelligence Quotient (IQ) score, with a mean of 100 and a standard deviation (SD) of 15. **1. Why Borderline Intellectual Functioning is correct:** Borderline Intellectual Functioning (BIF) describes a range of intelligence that falls between average cognitive ability and intellectual disability. According to the DSM-5 and ICD-10, this corresponds to an **IQ score of 70 to 79** (roughly 1 to 2 standard deviations below the mean). Individuals in this range often struggle with complex academic tasks but do not meet the full diagnostic criteria for an Intellectual Disability (ID). **2. Analysis of Incorrect Options:** * **Mild Intellectual Disability (IQ 50–69):** This is the most common form of ID (85%). These individuals are "educable" and can achieve academic skills up to the 6th-grade level. * **Moderate Intellectual Disability (IQ 35–49):** These individuals are "trainable." They can perform supervised tasks and achieve academic skills up to the 2nd-grade level. * **Normal Intelligence (IQ 90–109):** This represents the average range where the majority of the population resides. **3. High-Yield Clinical Pearls for NEET-PG:** * **Intellectual Disability (ID) Criteria:** Diagnosis requires deficits in both **intellectual functioning** (IQ <70) and **adaptive functioning** (conceptual, social, and practical domains) with onset during the developmental period. * **IQ Ranges (ICD-10):** * **Mild:** 50–69 * **Moderate:** 35–49 * **Severe:** 20–34 * **Profound:** <20 * **Most Common Cause of ID:** Genetic (Down Syndrome is the most common chromosomal cause; Fragile X is the most common inherited cause). * **Binet-Simon Scale:** The first formal scale to measure intelligence.

Q: Nowadays, Down syndrome is referred to as:

Submental disorder. **Explanation:** The terminology used to describe intellectual and developmental disabilities has evolved significantly to reduce stigma and improve clinical accuracy. In modern psychiatric and medical nomenclature, Down syndrome is classified under the umbrella of **Submental disorders** (or sub-average mental functioning). This term reflects the cognitive impairment and intellectual disability (ID) characteristic of the condition, where the Intelligence Quotient (IQ) is typically below 70, accompanied by deficits in adaptive functioning. **Analysis of Options:** * **A. Submental disorder (Correct):** This is the current preferred clinical descriptor for conditions involving intellectual deficits. It aligns with the classification of Down syndrome as a primary cause of intellectual disability. * **B. Oligophrenia:** This is an archaic term (derived from Greek, meaning "few mind") formerly used to describe intellectual disability. While historically accurate, it is no longer used in modern clinical practice or the DSM-5/ICD-11. * **C. Madness:** This is a non-medical, derogatory lay term historically used for psychosis or severe mental illness. It lacks clinical validity. * **D. Mentally unstable:** This is a vague, non-diagnostic term often used to describe mood lability or personality disorders, rather than the stable, developmental cognitive impairment seen in Down syndrome. **Clinical Pearls for NEET-PG:** * **Genetics:** Most common cause of genetic intellectual disability; 95% of cases are due to **Trisomy 21 (Nondisjunction)**. * **Cytogenetics:** 4% are due to **Robertsonian Translocation** (usually 14;21), and 1% are **Mosaicism**. * **Psychiatric Comorbidity:** Increased risk of ADHD, Autism Spectrum Disorder, and early-onset **Alzheimer’s disease** (due to the APP gene on chromosome 21). * **Screening:** First-trimester screening includes nuchal translucency (increased) and PAPP-A (decreased).

Q: Rett's syndrome is characterized by all of the following EXCEPT?

Decreased head circumference at birth. **Explanation:** Rett’s Syndrome is a unique neurodevelopmental disorder caused by a mutation in the **MECP2 gene** on the X chromosome. The hallmark of this condition is a period of normal early development followed by a rapid regression of acquired skills. **Why Option D is the Correct Answer:** In Rett’s syndrome, the **head circumference at birth is typically normal**. The characteristic clinical feature is **deceleration of head growth** (acquired microcephaly) occurring between 5 months and 4 years of age. Therefore, saying the head circumference is decreased *at birth* is factually incorrect. **Analysis of Other Options:** * **Option A (Common in girls):** This is true. Because it is an X-linked dominant condition that is usually lethal in hemizygous males, it is seen almost exclusively in females. * **Option B (Severe mental retardation):** This is true. Most children with Rett’s syndrome develop profound intellectual disability along with loss of purposeful hand movements and communication skills. * **Option C (Hand wringing present):** This is a pathognomonic feature. Patients lose purposeful hand skills and replace them with stereotypical movements, most commonly **hand-wringing**, clapping, or washing motions. **High-Yield Clinical Pearls for NEET-PG:** * **Stages:** It involves four stages: Early onset stagnation, Rapid destruction (regression), Pseudo-stationary, and Late motor deterioration. * **Breathing Abnormalities:** Episodes of hyperventilation and apnea are common during wakefulness. * **Social Interaction:** Unlike Autism, children with Rett’s syndrome may show a transient improvement in social interaction (the "social plateau") after the initial regression phase. * **Genetic Locus:** MECP2 gene on Xq28.

Q: A 6-year-old child with a history of birth asphyxia has poor communication, slow mental and physical growth, social withdrawal, limited interests, and becomes agitated when disturbed. What is the most likely diagnosis?

Autistic disorder. ### Explanation The clinical presentation described is characteristic of **Autistic Disorder** (now part of Autism Spectrum Disorder - ASD). The diagnosis is based on a triad of impairments: 1. **Social Impairment:** Social withdrawal and poor communication. 2. **Communication Deficits:** Slow mental growth and poor verbal/non-verbal interaction. 3. **Restricted/Repetitive Behaviors:** Limited interests and agitation when routines are disturbed (insistence on sameness). Birth asphyxia is a known prenatal/perinatal risk factor for neurodevelopmental delays, including ASD. **Analysis of Incorrect Options:** * **Hyperkinetic Disorder / ADHD (Options A & C):** These are characterized by a persistent pattern of inattention, hyperactivity, and impulsivity. While children with ADHD may have social difficulties, they do not typically exhibit the profound deficits in social communication or the "insistence on sameness" seen in Autism. * **Schizophrenia (Option D):** Childhood-onset schizophrenia is rare before age 13. It presents with hallucinations, delusions, and thought disorders rather than the developmental delays in social and motor milestones described here. **Clinical Pearls for NEET-PG:** * **Age of Onset:** Symptoms of ASD must be present in the early developmental period (typically recognized by age 3). * **Kanner’s Syndrome:** An older term for classic Autistic Disorder. * **Key Sign:** Lack of "joint attention" (e.g., not pointing to objects of interest) is a major early red flag. * **Comorbidity:** Intellectual disability is present in approximately 70% of cases, though "High-functioning Autism" (formerly Asperger’s) presents with normal IQ and language.

Q: Which of the following SSRIs is used in childhood depression?

fluoxetine. **Explanation:** **Fluoxetine** is the correct answer because it is the only SSRI (Selective Serotonin Reuptake Inhibitor) consistently recommended as the **first-line pharmacological treatment** for Major Depressive Disorder (MDD) in children and adolescents. It is the only antidepressant with robust evidence for efficacy in this age group and is FDA-approved for pediatric depression (ages 8 and older). **Analysis of Options:** * **Fluoxetine (Option A):** Correct. It has a long half-life, which reduces withdrawal symptoms and provides a stable plasma concentration, making it safer for pediatric use. * **Duloxetine (Option B):** This is an SNRI (Serotonin-Norepinephrine Reuptake Inhibitor). While used for pediatric Generalized Anxiety Disorder (GAD), it is not the first-line choice for childhood depression. * **Citalopram (Option C):** Although an SSRI, it is generally considered second-line due to weaker evidence of efficacy in children compared to fluoxetine and concerns regarding QTc prolongation at higher doses. * **Milnacipran (Option D):** This is an SNRI primarily used for fibromyalgia in adults; it has no established role in treating childhood depression. **High-Yield Clinical Pearls for NEET-PG:** * **First-line management:** For mild depression, psychotherapy (CBT or Interpersonal Therapy) is preferred. For moderate-to-severe depression, **Fluoxetine + CBT** is the gold standard. * **Black Box Warning:** All SSRIs carry a warning regarding the increased risk of **suicidal ideation** and behavior in children, adolescents, and young adults (up to age 24). * **FDA Approvals:** Fluoxetine (MDD ≥8 years; OCD ≥7 years) and Sertraline (OCD ≥6 years). Escitalopram is also approved for MDD in adolescents (12-17 years).

Q: Which of the following subtypes of ADHD is common in girls?

Inattentive Type. **Explanation:** Attention-Deficit Hyperactivity Disorder (ADHD) is a neurodevelopmental disorder characterized by a persistent pattern of inattention and/or hyperactivity-impulsivity. According to the DSM-5, ADHD is classified into three main presentations: Predominantly Inattentive, Predominantly Hyperactive-Impulsive, and Combined type. **Why Inattentive Type is correct:** Epidemiological studies consistently show that while ADHD is more frequently diagnosed in boys (who often present with disruptive, externalizing behaviors), the **Inattentive Type** is the most common presentation in **girls**. Girls often exhibit "internalizing" symptoms such as daydreaming, difficulty following instructions, and academic underachievement rather than physical restlessness. Because these symptoms are less disruptive in a classroom setting, girls are frequently diagnosed later in life compared to boys. **Analysis of Incorrect Options:** * **A & B (Hyperactive/Impulsive Types):** These symptoms are characterized by "externalizing" behaviors (fidgeting, running, interrupting). These are significantly more common in **boys**. * **D (Autistic Type):** This is not a subtype of ADHD. Autism Spectrum Disorder (ASD) is a separate neurodevelopmental diagnosis, though it can be comorbid with ADHD. **High-Yield Clinical Pearls for NEET-PG:** * **Male to Female Ratio:** Approximately 3:1 in clinical samples (though the gap narrows in adulthood). * **Age of Onset:** Symptoms must be present before **age 12** (DSM-5 criteria). * **Setting:** Symptoms must be present in **two or more settings** (e.g., home and school). * **First-line Treatment:** Psychostimulants (e.g., **Methylphenidate**) are the gold standard. Non-stimulant options include **Atomoxetine** (a selective NE reuptake inhibitor).

Q: Coprolalia is an important symptom for which of the following disorders?

Tourette's disorder. **Explanation:** **Tourette’s Disorder (Correct Answer):** Tourette’s Disorder is a neurodevelopmental condition characterized by the presence of **multiple motor tics** and at least **one vocal tic** for a duration of more than one year, with onset before age 18. **Coprolalia**, the involuntary utterance of socially taboo or obscene words, is a classic (though not mandatory) symptom of Tourette’s, occurring in approximately 10–15% of cases. It arises due to a failure of inhibitory control in the cortico-striato-thalamo-cortical (CSTC) circuits. **Incorrect Options:** * **Anxiety Disorder:** While anxiety can exacerbate tics, it does not manifest as coprolalia. Anxiety disorders typically present with excessive worry, autonomic hyperactivity, or avoidance behaviors. * **Avoidant Personality Disorder:** This is a Cluster C personality disorder characterized by social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation. It involves no motor or vocal tics. * **Stereotypic Movement Disorder:** This involves repetitive, driven, and non-functional motor behavior (e.g., hand waving, body rocking). Unlike tics, these movements are rhythmic and lack the "premonitory urge" and vocal components like coprolalia. **Clinical Pearls for NEET-PG:** * **Diagnostic Criteria:** Both motor and vocal tics must be present for >1 year for a diagnosis of Tourette’s. * **Associated Comorbidities:** The most common comorbidities are **ADHD** (most common) and **OCD**. * **Treatment:** First-line behavioral therapy is **CBIT** (Comprehensive Behavioral Intervention for Tics). Pharmacotherapy includes Alpha-2 agonists (Clonidine/Guanfacine) or atypical antipsychotics (Risperidone/Aripiprazole). * **Related terms:** **Copropraxia** (involuntary obscene gestures) and **Echolalia** (repeating others' words) are also seen in Tourette’s.

Question 1

A 4-year-old girl who stas school has never shown much interest in interacting with others. She has never used many words, which her parents attribute to her isolation as an only child. She has always done best with a strict schedule and does not tolerate changes well. Other children attempt to play with her, but her response is to either ignore them or get angry at their advances. How can the patient described be best distinguished from Rett disorder?

Accepted Answer

Absence of a period of normal development

Answer

Social difficulties

Answer

Lack of language development

Answer

Evidence of mental retardation

Question 2

A 7-year-old child exhibits conservative behavior, has difficulty playing quietly with peers, and struggles with organization. The child also interrupts others in school and is easily distracted. Which of the following is the likely diagnosis?

Accepted Answer

Attention deficit hyperactivity disorder

Answer

Learning disorder

Answer

Autistic disorder

Answer

Conduct disorder

Question 3

Which of the following conditions is seen predominantly in females?

Accepted Answer

Rett syndrome

Answer

Autism

Answer

Asperger syndrome

Answer

Cornelia de Lange syndrome

Question 4

An IQ score between 70-75 denotes which of the following intellectual functioning levels?

Accepted Answer

Borderline intellectual functioning

Answer

Mild intellectual disability

Answer

Moderate intellectual disability

Answer

Normal intelligence

Question 5

Nowadays, Down syndrome is referred to as:

Accepted Answer

Submental disorder

Answer

Oligophrenia

Answer

Madness

Answer

Mentally unstable

Question 6

Rett's syndrome is characterized by all of the following EXCEPT?

Accepted Answer

Decreased head circumference at birth

Answer

Common in girls

Answer

Severe mental retardation

Answer

Hand wringing present

Question 7

A 6-year-old child with a history of birth asphyxia has poor communication, slow mental and physical growth, social withdrawal, limited interests, and becomes agitated when disturbed. What is the most likely diagnosis?

Accepted Answer

Autistic disorder

Answer

Hyperkinetic disorder

Answer

Attention deficit disorder

Answer

Schizophrenia

Question 8

Which of the following SSRIs is used in childhood depression?

Accepted Answer

fluoxetine

Answer

duloxetine

Answer

citalopram

Answer

milnacipran

Question 9

Which of the following subtypes of ADHD is common in girls?

Accepted Answer

Inattentive Type

Answer

Hyperactive Type

Answer

Impulsive Type

Answer

Autistic Type

Question 10

Coprolalia is an important symptom for which of the following disorders?

Accepted Answer

Tourette's disorder

Answer

Anxiety disorder

Answer

Avoidant personality disorder

Answer

Stereotypic movement disorder

Child and Adolescent Psychiatry — MCQs

Child and Adolescent Psychiatry — MCQs

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