Psychiatric Emergencies in Children — MCQs
Which of the following will have an organic cause?
Which of the following is LEAST preferred as first-line treatment for pediatric status epilepticus?
Extrapyramidal syndrome-like side effects are seen in which of the following medications?
A 9-year-old child is restless. He is hyperactive, and his teacher complains that he does not listen to the teachings, disturbs other students, and shows less interest in playing. The likely diagnosis is?
Which of the following findings is LEAST likely to be associated with battered child syndrome?
Which of the following tests for criminal responsibility of the insane takes into account loss of self control?
Which of the following factors is least likely to be associated with suicidal tendencies?
A patient has a history of vomiting and was given an antiemetic. The patient subsequently developed abnormal movements (likely extrapyramidal symptoms or dystonia). What medication should be given to manage these abnormal movements?
An unconscious child is brought to the casualty. What is the correct sequence of the management?
Which of the following disorders is classified under somatic symptom and related disorders in the DSM-5?
Psychiatric Emergencies in Children Indian Medical PG Practice Questions and MCQs
Question 1: Which of the following will have an organic cause?
- A. Schizophrenia
- B. Delirium (Correct Answer)
- C. Anxiety
- D. Obsessive compulsive disorder
Explanation: ***Delirium*** - Delirium is an **acute, fluctuating disturbance of consciousness** and cognition that is directly caused by a **medical condition**, substance intoxication/withdrawal, or medication side effect [1], [2], [3]. - It always has an **underlying organic etiology** such as infection, metabolic derangements, drug toxicity, or neurological disorders [1], [2]. *Schizophrenia* - Schizophrenia is a **chronic psychiatric disorder** characterized by psychosis (hallucinations, delusions), disorganized thinking, and negative symptoms. - While it has a neurobiological basis, it is considered a **primary mental illness** and not typically caused by an acute, identifiable organic illness in the way delirium is. *Anxiety* - Anxiety disorders are characterized by excessive worry, fear, and physical symptoms of arousal. They are considered **primary mental health conditions**. - Although stress can precipitate anxiety, it is not primarily due to a **specific acute organic cause** that resolves with treatment of that cause. *Obsessive compulsive disorder* - Obsessive-compulsive disorder (OCD) is an anxiety-related disorder characterized by **recurrent, intrusive thoughts (obsessions)** and repetitive behaviors (compulsions) aimed at reducing distress. - Like other primary mental health conditions, it has a neurobiological basis but is not classified as having an **acute organic cause** in the medical sense.
Question 2: Which of the following is LEAST preferred as first-line treatment for pediatric status epilepticus?
- A. Clonazepam (Correct Answer)
- B. Fosphenytoin
- C. Diazepam
- D. Phenobarbital
Explanation: ***Clonazepam*** - While a benzodiazepine, **clonazepam** is generally not considered a first-line agent for acute status epilepticus due to its **slower onset of action** compared to other benzodiazepines like midazolam or diazepam. - Its longer half-life also makes it less ideal for rapid termination of seizures when immediate action is needed to prevent neuronal injury. *Fosphenytoin* - **Fosphenytoin** is a **prodrug of phenytoin** that is often used as a second-line agent for status epilepticus after benzodiazepines have failed. - It can be administered more rapidly and has a lower risk of local injection site reactions compared to phenytoin, making it a viable option when first-line agents are insufficient. *Diazepam* - **Diazepam** is a **short-acting benzodiazepine** that is a preferred first-line treatment for status epilepticus, especially in the pre-hospital setting or as an initial hospital intervention. - It has a **rapid onset of action** when administered intravenously or rectally, effectively terminating seizures quickly. *Phenobarbital* - **Phenobarbital** is a **barbiturate** that acts as a potent anticonvulsant and is considered a second-line or third-line treatment option for status epilepticus, particularly in pediatric patients. - While effective, its use is often reserved for cases unresponsive to benzodiazepines due to its potential for **respiratory depression** and sedative effects.
Question 3: Extrapyramidal syndrome-like side effects are seen in which of the following medications?
- A. Haloperidol (Correct Answer)
- B. Clozapine
- C. Tetracycline
- D. Ketoconazole
Explanation: ***Haloperidol*** - **Haloperidol** is a **typical antipsychotic** known for its potent **dopamine D2 receptor blockade**. - This strong blockade in the **nigrostriatal pathway** often leads to **extrapyramidal symptoms (EPS)** such as dystonia, akathisia, and parkinsonism. *Clozapine* - **Clozapine** is an **atypical antipsychotic** that has a lower propensity for causing **extrapyramidal symptoms (EPS)** due to its weaker D2 receptor antagonism and potent serotonin 5-HT2A receptor blockade. - While it can cause other severe side effects, such as **agranulocytosis** and **myocarditis**, EPS are less common compared to typical antipsychotics. *Tetracycline* - **Tetracycline** is an **antibiotic** primarily used to treat bacterial infections. - Its mechanism of action involves inhibiting bacterial protein synthesis, and it is not associated with **neurological side effects** like **extrapyramidal symptoms**. *Ketoconazole* - **Ketoconazole** is an **antifungal medication** that works by inhibiting ergosterol synthesis in fungi. - It is known for potential **hepatotoxicity** and **endocrine dysfunction**, but not for causing **extrapyramidal symptoms**.
Question 4: A 9-year-old child is restless. He is hyperactive, and his teacher complains that he does not listen to the teachings, disturbs other students, and shows less interest in playing. The likely diagnosis is?
- A. Cerebral palsy
- B. Attention Deficit Hyperactivity Disorder (ADHD) (Correct Answer)
- C. Delirium
- D. Mania
Explanation: ***Attention Deficit Hyperactivity Disorder (ADHD)*** - The symptoms described, such as **restlessness**, **hyperactivity**, **difficulty listening**, and **disturbing others**, are classic indicators of **Attention Deficit Hyperactivity Disorder** in a child. - ADHD is characterized by a persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development. - The decreased interest in playing may reflect difficulty with **structured play activities** or **peer interactions** rather than lack of interest in play itself, which can occur in ADHD due to impulsivity and inattention affecting social relationships. *Cerebral palsy* - **Cerebral palsy** is a group of permanent movement disorders that appear in early childhood and primarily affect **muscle coordination and motor control**. - It does not explain the behavioral and attentional issues described in the case, and the focus here is on behavioral problems rather than motor dysfunction. *Delirium* - **Delirium** is an acute, fluctuating disturbance in attention and cognition, often caused by an underlying medical condition, substance intoxication, or withdrawal. - It typically has an **abrupt onset** and waxing-waning course with altered consciousness, which is not consistent with the chronic, stable presentation in this child. *Mania* - **Mania** is a state of elevated, expansive, or irritable mood and increased goal-directed activity or energy, typically seen in **bipolar disorder**. - While it can involve **hyperactivity** and distractibility, mania would present with **elevated/irritable mood**, **decreased need for sleep**, **pressured speech**, and **grandiosity**, which are not described here. The symptom complex is more consistent with the developmental disorder of ADHD.
Question 5: Which of the following findings is LEAST likely to be associated with battered child syndrome?
- A. Subdural hematoma
- B. Skin bruising
- C. Failure to thrive (Correct Answer)
- D. Multiple fractures in different stages of healing
Explanation: ***Failure to thrive*** - While **neglect** can lead to failure to thrive, it is **less directly indicative** of battered child syndrome compared to specific traumatic injuries - Failure to thrive reflects **chronic malnutrition and inadequate care** rather than acute physical abuse - Battered child syndrome primarily involves **physical trauma** (fractures, bruises, head injuries) rather than growth deficiencies - Of all the options, this finding is **LEAST characteristic** of direct physical battering *Subdural hematoma* - **Highly associated** with battered child syndrome, particularly in **abusive head trauma** (shaken baby syndrome) - Results from tearing of bridging veins due to violent shaking or impact - One of the most serious manifestations of physical abuse in children *Skin bruising* - The **most common visible sign** of physical abuse in children - Multiple bruises in **different stages of healing** and in unusual locations (face, neck, trunk, buttocks) are highly suspicious - Pattern bruising (hand prints, belt marks, loop marks) is pathognomonic of abuse *Multiple fractures in different stages of healing* - **Classic radiologic finding** in battered child syndrome - Metaphyseal corner fractures and posterior rib fractures are particularly specific for abuse - Different stages of healing indicate repeated episodes of trauma
Question 6: Which of the following tests for criminal responsibility of the insane takes into account loss of self control?
- A. Irresistible Impulse Test (Correct Answer)
- B. Durham rule
- C. Right or wrong test
- D. ALI Test (Model Penal Code Test)
Explanation: ***Irresistible Impulse Test*** - This test **specifically focuses on the volitional aspect** (loss of self-control) of criminal responsibility. - It considers a defendant not guilty if a mental disease or defect caused them to experience an **uncontrollable urge** to commit the crime, even if they knew it was wrong. - This test directly addresses the inability to **control one's actions** despite knowing right from wrong, which is exactly what the question asks for. - It was developed to address the limitation of the M'Naghten Rule, which only considered cognitive capacity (knowing right from wrong). *ALI Test (Model Penal Code Test)* - This is a modern, **comprehensive test** that combines BOTH cognitive (right/wrong) AND volitional (loss of self-control) aspects. - While it does include a volitional component ("conform their conduct to the requirements of law"), it is not specifically or exclusively focused on loss of self-control. - It states a person is not responsible if they lack substantial capacity either to **appreciate the criminality** of their conduct OR to **conform their conduct** to the law. *Durham rule* - The Durham rule (the **"product test"**) states that an accused is not criminally responsible if their unlawful act was the **product of mental disease or defect**. - This rule is very broad and does not specifically address loss of self-control; it simply links the criminal act to mental illness. - It was largely abandoned because it allowed for excessive psychiatric testimony and blurred legal and medical definitions. *Right or wrong test* - This is the traditional **M'Naghten Rule**, which focuses solely on **cognitive capacity** (knowing right from wrong). - It does **NOT account for loss of self-control** at all - even if a defendant knew an act was wrong but couldn't control themselves, they would still be found guilty under this test. - This limitation led to the development of the Irresistible Impulse Test as a supplement.
Question 7: Which of the following factors is least likely to be associated with suicidal tendencies?
- A. Social isolation
- B. Mental health issues
- C. Gender
- D. Being married (Correct Answer)
Explanation: ***Being married*** - Marriage, particularly a strong and supportive relationship, is often considered a **protective factor** against suicidal ideation and acts. - The presence of a partner and shared responsibilities can provide a sense of **belonging** and **purpose**, reducing feelings of hopelessness. *Social isolation* - **Lack of social support** and feelings of loneliness significantly increase the risk of suicidal thoughts and behaviors. - Individuals who feel isolated may experience a deeper sense of **despair** and have fewer resources to cope with stress. *Mental health issues* - Conditions like **depression**, **bipolar disorder**, **schizophrenia**, and **anxiety disorders** are strong risk factors for suicidal tendencies. - These illnesses often lead to severe emotional distress, impaired judgment, and feelings of worthlessness. *Gender* - While women are more likely to attempt suicide, **men are more likely to die by suicide**, using more lethal means. - This difference indicates that gender is a significant factor in the **epidemiology** and presentation of suicidal behaviors, not a protective one.
Question 8: A patient has a history of vomiting and was given an antiemetic. The patient subsequently developed abnormal movements (likely extrapyramidal symptoms or dystonia). What medication should be given to manage these abnormal movements?
- A. Hyoscine
- B. Methyl dopa
- C. Benzhexol (Correct Answer)
- D. Cyproheptadine
- E. Diphenhydramine
Explanation: ***Benzhexol*** - **Extrapyramidal symptoms (EPS)** and **dystonia** are often caused by dopamine receptor blockade, and **anticholinergic medications** like benzhexol help restore the **dopamine-acetylcholine balance**. - Benzhexol is a **muscarinic antagonist** that effectively reduces drug-induced Parkinsonism, dystonia, and akathisia by acting centrally. - It is the **preferred oral agent** for ongoing management of drug-induced movement disorders. *Diphenhydramine* - Diphenhydramine is an **antihistamine** with **anticholinergic properties** that can be used for **acute dystonic reactions**, particularly when given parenterally (IV/IM). - While effective for acute management, benzhexol is generally preferred for **ongoing oral therapy** and has more potent central anticholinergic effects. *Hyoscine* - While hyoscine is also an **anticholinergic agent**, it is primarily used for preventing **motion sickness** and managing **postoperative nausea and vomiting**. - Its efficacy in reversing acute extrapyramidal symptoms induced by neuroleptics or antiemetics is generally **less pronounced** compared to agents like benzhexol. *Methyl dopa* - Methyl dopa is an **alpha-2 adrenergic agonist** primarily used in the treatment of **hypertension**, especially in pregnancy. - It works by reducing sympathetic outflow and is **not indicated** for managing extrapyramidal symptoms or dystonia. *Cyproheptadine* - Cyproheptadine is an **antihistamine** with **serotonin antagonist** properties, used to treat allergic reactions, appetite stimulation, and occasionally **serotonin syndrome**. - It does not have significant anticholinergic effects that would alleviate medication-induced extrapyramidal symptoms or dystonia.
Question 9: An unconscious child is brought to the casualty. What is the correct sequence of the management?
- A. Circulation, Airway, Breathing
- B. Breathing, Circulation, Airway
- C. Circulation, Breathing, Airway
- D. Airway, Breathing, Circulation (Correct Answer)
Explanation: ***Airway, Breathing, Circulation*** - The **ABC sequence** is the cornerstone of pediatric resuscitation as per **PALS (Pediatric Advanced Life Support) guidelines** - In an unconscious child, a patent **airway** is the absolute first priority - without this, no oxygen can reach the lungs regardless of breathing effort - Once airway patency is ensured, **breathing** must be assessed and supported to provide adequate ventilation and oxygenation - Only after securing airway and breathing should **circulation** be addressed, as effective circulation without oxygenation is futile - This sequence prevents **hypoxic brain injury**, which can occur within 4-6 minutes of oxygen deprivation *Circulation, Airway, Breathing* - This violates the fundamental **ABC principle** of emergency management - Prioritizing **circulation** before establishing a patent **airway** means attempting to circulate deoxygenated blood - Without airway patency, any circulatory support will fail to deliver oxygen to vital organs, leading to **irreversible hypoxic damage** - In pediatric emergencies, respiratory failure is more common than primary cardiac arrest, making airway management even more critical *Breathing, Circulation, Airway* - Attempting to support **breathing** before securing the **airway** is physiologically ineffective - An obstructed airway prevents air entry despite breathing efforts or bag-mask ventilation attempts - This sequence can lead to **gastric distension, aspiration**, and worsening hypoxia - Delays in airway management increase the risk of **cardiac arrest** from prolonged hypoxemia *Circulation, Breathing, Airway* - This sequence dangerously delays **airway management**, the most time-critical intervention - In an unconscious child, airway obstruction from tongue falling back or secretions is common and immediately life-threatening - Without a patent airway, neither breathing support nor circulatory measures can prevent **brain death** from anoxia - Following this sequence contradicts all **international resuscitation guidelines** (PALS, AHA, ERC)
Question 10: Which of the following disorders is classified under somatic symptom and related disorders in the DSM-5?
- A. Post-Traumatic Stress Disorder (PTSD)
- B. Phobic disorders (e.g., social anxiety disorder)
- C. Conversion disorder (functional neurological symptom disorder) (Correct Answer)
- D. Obsessive-Compulsive Disorder (OCD)
Explanation: ***Conversion disorder (functional neurological symptom disorder)*** - **Conversion disorder** is characterized by neurological symptoms (e.g., paralysis, blindness) that are **incompatible with recognized neurological or medical conditions**, yet are not intentionally produced. - It falls under **somatic symptom and related disorders** because the primary features are physical symptoms causing distress or functional impairment, rather than being malingered or feigned. *Phobic disorders (e.g., social anxiety disorder)* - **Phobic disorders** are classified under **anxiety disorders** in the DSM-5, not somatic symptom and related disorders. - They are primarily characterized by **intense, irrational fears** of specific objects or situations, leading to avoidance rather than prominent physical symptoms without a medical cause. *Post-Traumatic Stress Disorder (PTSD)* - **PTSD** is classified under **trauma- and stressor-related disorders** in the DSM-5, distinguished by symptoms developing after exposure to a traumatic event. - Its core features include **intrusive memories, avoidance, negative alterations in cognition and mood, and alterations in arousal and reactivity**, rather than unexplained physical symptoms. *Obsessive-Compulsive Disorder (OCD)* - **OCD** is classified under **obsessive-compulsive and related disorders** in the DSM-5. - It is primarily characterized by the presence of **obsessions (recurrent, intrusive thoughts)** and/or **compulsions (repetitive behaviors or mental acts)**, which are distinct from somatic symptoms.
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