A 7-year-old girl is brought to the GP by her foster carer who has concerns about her behaviour. The girl has been in foster care for 3 months following removal from her biological parents due to neglect. The carer reports that the child is indiscriminately affectionate with strangers, shows no anxiety around unfamiliar adults, and has difficulty maintaining friendships. She struggles with emotional regulation and has frequent tantrums. Which attachment pattern is most consistent with this presentation?
Q122
A 3-year-old boy presents to the emergency department with his mother who reports he fell off a sofa. On examination, there are multiple bruises of different colours on both shins and knees, and a single bruise on the left forehead. The child is playful and interactive. His mother explains he is very active and accident-prone. What feature would be most concerning for non-accidental injury in this presentation?
Q123
A paediatric registrar is teaching medical students about patterns of growth. A parent asks why their 6-month-old baby, who was born on the 75th centile for weight, is now tracking along the 50th centile despite being exclusively breastfed and thriving. Which phenomenon best explains this pattern of growth?
Q124
A health visitor assesses a 12-month-old infant who was born at 32 weeks gestation. The child can sit unsupported, transfers objects between hands, and has a pincer grip. The parents are concerned because their friend's term baby of the same age is already walking independently. What is the most appropriate corrected age for developmental assessment of this child?
Q125
A 5-month-old infant is brought to the GP for a developmental check. The parents report that the baby can roll from prone to supine, holds their head steady when pulled to sit, and reaches for objects with both hands. The baby smiles and vocalizes when played with. On examination, the infant fixes and follows objects through 180 degrees. Which primitive reflex would you expect to still be present at this age?
Q126
A 3-year-old boy with autism spectrum disorder is reviewed in a developmental clinic. His mother reports he has approximately 15 single words but does not join words together, makes limited eye contact, and prefers solitary play with toy cars which he lines up repeatedly. He becomes very distressed with changes to routine. Height and weight are on the 50th centile. Which developmental domain is most likely to show relative strength in children with autism spectrum disorder compared to their other developmental domains?
Q127
A GP receives a phone call from a teacher concerned about a 9-year-old boy who has disclosed that 'daddy hits mummy'. The child has not reported being hit himself but appears anxious and his school performance has deteriorated. The mother attends the surgery regularly for minor ailments and has previously been seen with bruising which she attributed to being 'clumsy'. What is the most appropriate action?
Q128
A 8-month-old infant is reviewed in clinic with concern about head growth. The head circumference has increased from the 50th centile at birth to the 98th centile now. The infant was born at term following a normal pregnancy, is meeting developmental milestones appropriately, and examination reveals no dysmorphic features or neurological abnormalities. Both parents have head circumferences above the 91st centile. What is the most likely diagnosis?
Q129
A foundation doctor sees a 13-year-old girl who presents with her aunt requesting emergency contraception after sexual intercourse with her 15-year-old boyfriend 36 hours ago. She appears mature for her age and states the relationship is consensual and she does not want her parents to know. What is the most appropriate immediate management regarding safeguarding?
Q130
A health visitor conducts a 2-year developmental check on a boy born at 30 weeks gestation. He can walk independently, scribble with a crayon, feed himself with a spoon, and says about 6 clear words. His parents are concerned about his development. What is the most appropriate interpretation of this developmental assessment?
Growth, Development & Safeguarding UK Medical PG Practice Questions and MCQs
Question 121: A 7-year-old girl is brought to the GP by her foster carer who has concerns about her behaviour. The girl has been in foster care for 3 months following removal from her biological parents due to neglect. The carer reports that the child is indiscriminately affectionate with strangers, shows no anxiety around unfamiliar adults, and has difficulty maintaining friendships. She struggles with emotional regulation and has frequent tantrums. Which attachment pattern is most consistent with this presentation?
A. Secure attachment
B. Insecure avoidant attachment
C. Insecure ambivalent attachment
D. Disorganized attachment
E. Disinhibited social engagement disorder (Correct Answer)
Explanation: ***Disinhibited social engagement disorder***
- Characterized by **indiscriminate sociability**, including a lack of reticence with unfamiliar adults and overly familiar physical or verbal behavior.
- Strongly associated with histories of **pathological neglect** or frequent changes in **primary caregivers**, preventing the formation of stable, selective attachments.
*Secure attachment*
- Children with this pattern use the caregiver as a **secure base** for exploration and show a clear preference for them over strangers.
- They exhibit **age-appropriate distress** upon separation and are easily soothed upon the caregiver's return.
*Insecure avoidant attachment*
- Characterized by children who appear **indifferent** to the caregiver's presence and show little distress when they leave.
- These children often **avoid contact** with caregivers upon reunion and treat strangers similarly to the primary caregiver but without seeking intense affection.
*Insecure ambivalent attachment*
- Marked by high levels of **separation anxiety** and extreme distress when the caregiver leaves.
- Upon reunion, the child often displays **conflicting behaviors**, such as seeking closeness while simultaneously showing anger or resistance towards the caregiver.
*Disorganized attachment*
- Often results from the caregiver being a source of **fear**, leading to contradictory behaviors like freezing or wandering aimlessly.
- While it involves significant emotional dysregulation, it is distinct from the **indiscriminate outgoingness** seen in disinhibited social engagement disorder.
Question 122: A 3-year-old boy presents to the emergency department with his mother who reports he fell off a sofa. On examination, there are multiple bruises of different colours on both shins and knees, and a single bruise on the left forehead. The child is playful and interactive. His mother explains he is very active and accident-prone. What feature would be most concerning for non-accidental injury in this presentation?
A. Multiple bruises on the shins and knees
B. Bruises of different colours
C. The child's age of 3 years
D. Bruising to the left forehead
E. Bruising on the soft tissues of the cheeks (Correct Answer)
Explanation: ***Bruising on the soft tissues of the cheeks***- Bruising on **soft tissues** such as the cheeks, ears, neck, or buttocks is highly suspicious for **non-accidental injury (NAI)** as these areas are typically protected from accidental falls.- Clinical guidelines use mnemonics like **TEN-4** (Torso, Ears, Neck) to identify high-risk bruising locations that require a thorough **safeguarding assessment**.*Multiple bruises on the shins and knees*- Bruises over **bony prominences** such as the shins and knees are very common in mobile, active children as they frequently trip and fall during play.- These locations are considered **accidental injury** patterns and are generally not concerning when the child is developmentally mobile.*Bruises of different colours*- While it was once thought that color could date a bruise, it is now accepted that **ageing of bruises by color** is scientifically unreliable.- In an active child, finding bruises in various stages of healing is normal and simply reflects multiple minor **accidental traumas** occurring at different times.*The child's age of 3 years*- A **3-year-old child** is highly mobile and developmentally expected to be running and jumping, which increases the likelihood of accidental bumps.- The phrase "those who don't cruise, don't bruise" applies to non-mobile infants; a mobile toddler with bruising is less concerning than a **non-mobile infant** with the same.*Bruising to the left forehead*- The forehead is a **bony prominence** that is a frequent site of impact when a child falls forward or bumps into furniture.- This location is consistent with the mother's explanation of an accidental fall and is considered a **typical accidental site** for bruising.
Question 123: A paediatric registrar is teaching medical students about patterns of growth. A parent asks why their 6-month-old baby, who was born on the 75th centile for weight, is now tracking along the 50th centile despite being exclusively breastfed and thriving. Which phenomenon best explains this pattern of growth?
A. Failure to thrive requiring investigation
B. Inadequate breast milk supply
C. Regression to the genetic target centile (Correct Answer)
D. Normal catch-down growth in breastfed infants
E. Constitutional growth delay
Explanation: ***Regression to the genetic target centile***
- During the first 6-12 months of life, infants often adjust their growth trajectory to align with their **genetic growth potential**, moving away from birth weight influenced by uterine factors.
- A shift from the 75th to the 50th centile is a normal adjustment, especially in a **thriving**, exclusively breastfed infant, and does not represent a significant deviation.
*Failure to thrive requiring investigation*
- **Failure to thrive** is typically defined by a more significant and sustained drop across more than two major centile lines, or persistently tracking below the 0.4th centile, neither of which applies here.
- The crucial detail is that the baby is described as **thriving**, which contradicts the definition of failure to thrive.
*Inadequate breast milk supply*
- An inadequate breast milk supply would usually manifest with more pronounced weight faltering, often crossing multiple centile lines, and clinical signs such as persistent hunger, infrequent wet/dirty diapers, or poor hydration.
- The infant is **thriving** and exclusively breastfed, suggesting adequate milk intake and nutritional status.
*Normal catch-down growth in breastfed infants*
- While breastfed infants' growth patterns can differ from formula-fed infants, especially after 3-4 months, the term "catch-down growth" is more specifically used for infants born **Large for Gestational Age (LGA)** or with a higher birth centile due to maternal factors, as they adjust towards their genetic potential.
- This option is less precise than 'regression to genetic target centile' for describing a healthy infant's growth adjustment.
*Constitutional growth delay*
- **Constitutional growth delay** is characterized by a normal growth velocity that falls below the population mean, leading to short stature in early childhood, often with a delayed **bone age** and a late pubertal spurt.
- This phenomenon typically presents later in childhood and is not the best explanation for the normal early infancy centile adjustment seen in a 6-month-old.
Question 124: A health visitor assesses a 12-month-old infant who was born at 32 weeks gestation. The child can sit unsupported, transfers objects between hands, and has a pincer grip. The parents are concerned because their friend's term baby of the same age is already walking independently. What is the most appropriate corrected age for developmental assessment of this child?
A. 10 months (Correct Answer)
B. 11 months
C. No correction needed at 12 months
D. Correct until 18 months chronological age
E. Correct until 24 months chronological age
Explanation: ***10 months***
- The **corrected age** is calculated by subtracting the number of weeks of **prematurity** (40 weeks minus gestational age) from the **chronological age**.
- Since the infant was born at **32 weeks** (8 weeks premature, or 2 months), their corrected age at 12 months chronological age is **10 months** (12 - 2 = 10 months).
*11 months*
- This option would be correct only if the infant was 4 weeks or **1 month premature** (born at 36 weeks gestation), which is not the case here.
- Using an incorrect corrected age can lead to misinterpreting a child's **developmental progress** as delayed or advanced.
*No correction needed at 12 months*
- Failing to correct for **prematurity** in infants born before **37 weeks gestation** can lead to an inaccurate assessment of their developmental milestones.
- Preterm infants typically reach milestones later than their full-term counterparts, and **age correction** accounts for this biological difference.
*Correct until 18 months chronological age*
- While some guidelines or specific assessments might adjust the correction period, the general consensus for **developmental assessment** is to correct for prematurity until at least 24 months of chronological age.
- Stopping correction too early may lead to an underestimation of potential **developmental delays** in some areas.
*Correct until 24 months chronological age*
- This option correctly identifies the widely accepted duration for **age correction** when assessing developmental milestones in preterm infants.
- It allows for a more accurate comparison of a preterm child's development against age-matched peers, considering their **biological age** rather than just chronological age.
Question 125: A 5-month-old infant is brought to the GP for a developmental check. The parents report that the baby can roll from prone to supine, holds their head steady when pulled to sit, and reaches for objects with both hands. The baby smiles and vocalizes when played with. On examination, the infant fixes and follows objects through 180 degrees. Which primitive reflex would you expect to still be present at this age?
A. Moro reflex
B. Asymmetric tonic neck reflex
C. Grasp reflex (Correct Answer)
D. Rooting reflex
E. Stepping reflex
Explanation: ***Grasp reflex***
- The **palmar grasp reflex** typically persists until around **6 months** of age, allowing it to be present in a 5-month-old infant.
- This reflex gradually integrates as the infant develops more **voluntary hand movements** and **fine motor control**, such as reaching and intentional grasping.
*Moro reflex*
- The **Moro reflex**, a startle reflex, normally disappears by **3 to 4 months** of age.
- Its persistence beyond 6 months can indicate **neurological immaturity** or damage.
*Asymmetric tonic neck reflex*
- The **Asymmetric tonic neck reflex (ATNR)**, or "fencing posture", usually integrates by **6 to 7 months** of age.
- While it can sometimes be present at 5 months, the **palmar grasp** is more reliably expected to be strong and present at this age, and the ATNR begins to diminish with increasing voluntary head control and rolling.
*Rooting reflex*
- The **rooting reflex** helps infants find the nipple for feeding and typically disappears by **4 months** of age.
- By 5 months, the infant has usually developed more **voluntary feeding behaviors**, making the absence of this reflex normal.
*Stepping reflex*
- The **stepping reflex** (or walking reflex) is one of the earliest primitive reflexes to disappear, typically integrating by **2 months** of age.
- Its early disappearance allows for the development of more **controlled leg movements** and weight bearing.
Question 126: A 3-year-old boy with autism spectrum disorder is reviewed in a developmental clinic. His mother reports he has approximately 15 single words but does not join words together, makes limited eye contact, and prefers solitary play with toy cars which he lines up repeatedly. He becomes very distressed with changes to routine. Height and weight are on the 50th centile. Which developmental domain is most likely to show relative strength in children with autism spectrum disorder compared to their other developmental domains?
A. Expressive language development
B. Social interaction and communication
C. Imaginative and symbolic play
D. Gross motor development (Correct Answer)
E. Receptive language and understanding
Explanation: ***Gross motor development***
- In children with **Autism Spectrum Disorder (ASD)**, **gross motor skills** are typically a relative strength, with milestones like walking and running usually achieved at the expected ages.
- Unlike the core deficits in social and communication domains, basic **physical coordination** and motor milestones do not form part of the diagnostic criteria for ASD.
*Expressive language development*
- **Expressive language** is frequently significantly delayed in ASD; this child only has 15 words and no **word joining** at age 3.
- Even when speech is present, it is often characterized by **echolalia**, pedantic speech, or atypical prosody rather than functional communication.
*Social interaction and communication*
- This is a core **diagnostic deficit** in ASD, manifested here by **limited eye contact** and a preference for solitary play.
- Children with ASD struggle with **social-emotional reciprocity**, which is a primary weakness rather than a strength.
*Imaginative and symbolic play*
- **Imaginative play** is typically impaired in ASD, replaced by **repetitive, non-functional play** such as lining up cars.
- The lack of **symbolic play** (using objects to represent something else) is a key clinical feature used to identify the disorder.
*Receptive language and understanding*
- **Receptive language** (understanding what others say) is often underdeveloped or inconsistent in children with ASD.
- Deficits in this area contribute to the **difficulty in following instructions** and adapting to changes in daily routines.
Question 127: A GP receives a phone call from a teacher concerned about a 9-year-old boy who has disclosed that 'daddy hits mummy'. The child has not reported being hit himself but appears anxious and his school performance has deteriorated. The mother attends the surgery regularly for minor ailments and has previously been seen with bruising which she attributed to being 'clumsy'. What is the most appropriate action?
A. No safeguarding referral needed as the child himself is not being physically abused
B. Contact the mother to discuss the concerns before making any referral
C. Make a child protection referral as witnessing domestic abuse is a safeguarding issue (Correct Answer)
D. Advise the teacher to monitor the situation and call back if there are further concerns
E. Refer the mother to adult social services for support with domestic abuse
Explanation: ***Make a child protection referral as witnessing domestic abuse is a safeguarding issue*** - Witnessing **domestic abuse** is classified as a form of **emotional abuse** and constitutes significant harm under safeguarding guidelines. - The child's **anxiety** and **deteriorating school performance** are clinical indicators that the home environment is negatively impacting his well-being, necessitating a formal **safeguarding referral**. *No safeguarding referral needed as the child himself is not being physically abused* - Physical harm is not required for a referral; **exposure to domestic violence** is a recognized category of **systemic child abuse**. - Professionals have a **legal duty** to protect children from the psychological and developmental damage caused by witnessing violence. *Contact the mother to discuss the concerns before making any referral* - In cases involving **domestic violence**, contacting the parent first can significantly increase the **risk of harm** to the victim and child if the perpetrator is alerted. - While parental engagement is usually preferred, it must be bypassed if it compromises the **safety** of those involved or the integrity of a potential investigation. *Advise the teacher to monitor the situation and call back if there are further concerns* - This approach is reactive and fails to address the **immediate risk** already identified by the child's disclosure and clinical symptoms. - A "wait and see" approach is inappropriate when there is ongoing **significant harm** occurring in the home environment. *Refer the mother to adult social services for support with domestic abuse* - While supporting the mother is important, the GP's primary duty in this scenario is to address the **child's safety** through **Children’s Social Care**. - An adult referral does not trigger the necessary **multi-agency response** required to ensure the child's specific developmental and protection needs are met.
Question 128: A 8-month-old infant is reviewed in clinic with concern about head growth. The head circumference has increased from the 50th centile at birth to the 98th centile now. The infant was born at term following a normal pregnancy, is meeting developmental milestones appropriately, and examination reveals no dysmorphic features or neurological abnormalities. Both parents have head circumferences above the 91st centile. What is the most likely diagnosis?
A. Hydrocephalus
B. Subdural haematoma from non-accidental injury
C. Familial macrocephaly (Correct Answer)
D. Brain tumour
E. Glutaric aciduria type 1
Explanation: ***Familial macrocephaly***
- This diagnosis is strongly suggested by the **normal development**, absence of neurological abnormalities, and the presence of **macrocephaly in both parents**.
- It is common for infants with this benign condition to **cross centiles** in the first year of life before their head growth curve eventually stabilizes.
*Hydrocephalus*
- Typically presents with signs of **raised intracranial pressure**, such as a bulging fontanelle, vomiting, or a "setting-sun" eye sign.
- Affected infants often show **developmental delay** or regression, which is not present in this case.
*Subdural haematoma from non-accidental injury*
- This would usually present acutely with **neurological deterioration**, seizures, or altered consciousness rather than isolated, steady head growth.
- Physical examination would likely reveal other markers of **trauma** or retinal hemorrhages rather than a normal physical exam.
*Brain tumour*
- Intracranial masses usually cause **focal neurological deficits**, irritability, or persistent vomiting due to mass effect.
- Rapid head growth from a tumor is rarely isolated; it is almost always accompanied by a loss of **developmental milestones**.
*Glutaric aciduria type 1*
- While it can cause macrocephaly, it typically presents with **acute encephalopathic crises** or movement disorders following a minor illness.
- Most children show **neurological deterioration** or hypotonia, which contrasts with this infant’s normal examination and development.
Question 129: A foundation doctor sees a 13-year-old girl who presents with her aunt requesting emergency contraception after sexual intercourse with her 15-year-old boyfriend 36 hours ago. She appears mature for her age and states the relationship is consensual and she does not want her parents to know. What is the most appropriate immediate management regarding safeguarding?
A. Provide emergency contraception and maintain confidentiality as she is Gillick competent
B. Refuse emergency contraception and inform parents immediately
C. Provide emergency contraception and make a child protection referral to social services
D. Assess Gillick competence, provide emergency contraception if competent, and discuss safeguarding concerns sensitively (Correct Answer)
E. Contact police immediately as this is statutory rape
Explanation: ***Assess Gillick competence, provide emergency contraception if competent, and discuss safeguarding concerns sensitively***
- Immediate management requires the clinician to assess **Gillick competence** to determine if the 13-year-old understands the implications and can make her own decision regarding emergency contraception. If competent, the contraception should be provided promptly.
- Despite her stated consent, her age (13) and the age of her boyfriend (15) trigger significant **safeguarding concerns**. These must be explored sensitively to identify any signs of **coercion, exploitation, or abuse**, while trying to maintain the patient's trust.
*Provide emergency contraception and maintain confidentiality as she is Gillick competent*
- Presuming **Gillick competence** without a thorough assessment is inappropriate, especially given the patient's age. A structured assessment is legally and ethically required.
- An absolute promise of **confidentiality** cannot be given to a 13-year-old in a situation with potential safeguarding risks. The doctor's primary duty is her safety, which may necessitate breaching confidentiality if serious harm is suspected.
*Refuse emergency contraception and inform parents immediately*
- Refusing **emergency contraception** is unethical, as it could lead to an **unwanted pregnancy**, which would be a greater harm to the patient.
- Informing parents immediately without assessing **Gillick competence** or discussing the implications with the patient would breach her trust and may not be in her best interests if she is found to be competent.
*Provide emergency contraception and make a child protection referral to social services*
- While a referral might ultimately be necessary, making an immediate **child protection referral** without a comprehensive, sensitive discussion with the patient and further assessment could be premature and erode her trust.
- The initial step should involve thorough exploration of the circumstances and consultation with a **named safeguarding lead** within the healthcare setting, before escalating to a formal referral to social services.
*Contact police immediately as this is statutory rape*
- While sexual activity with a person under 16 is legally concerning, the immediate response for a healthcare professional is primarily focused on the patient's medical and **safeguarding needs**, not immediate criminal reporting, especially in cases of peer-on-peer relationships with a small age difference.
- The focus should be on a **holistic safeguarding assessment** for potential harm, coercion, or exploitation, which may then inform whether police involvement is appropriate after discussion with safeguarding leads.
Question 130: A health visitor conducts a 2-year developmental check on a boy born at 30 weeks gestation. He can walk independently, scribble with a crayon, feed himself with a spoon, and says about 6 clear words. His parents are concerned about his development. What is the most appropriate interpretation of this developmental assessment?
A. Development is significantly delayed and urgent paediatric referral is required
B. Development is normal for chronological age and parents can be reassured
C. Development is appropriate for corrected age and can be monitored in primary care (Correct Answer)
D. Language delay is present and speech therapy referral should be made
E. Fine motor delay is present and occupational therapy assessment is needed
Explanation: ***Development is appropriate for corrected age and can be monitored in primary care*** - For a child born at 30 weeks gestation, the **corrected age** should be used for developmental assessment up to 2 years. His corrected age is 24 months (chronological age) minus 10 weeks prematurity (approx. 2.5 months), making it about **21.5 months**. - The milestones of independent walking, scribbling with a crayon, feeding with a spoon, and saying about 6 clear words are all **appropriate for a 21-month-old**, indicating normal development for his corrected age. *Development is significantly delayed and urgent paediatric referral is required* - The child is meeting key developmental milestones such as **independent walking** and early language, which indicates he is not significantly delayed when assessed against his corrected age. - **Urgent paediatric referral** is typically reserved for children with severe global developmental delay or regression, which is not suggested by this assessment. *Development is normal for chronological age and parents can be reassured* - Using **chronological age** (24 months) would be inappropriate for a preterm infant, as it would incorrectly suggest delays, especially in language. - A 2-year-old (chronological age) is typically expected to have a **vocabulary of 50 or more words** and combine 2-3 words, making 6 words appear delayed if not for corrected age. *Language delay is present and speech therapy referral should be made* - Speaking 6 clear words is **within the normal range for a 21-month-old** (corrected age), where vocabulary often ranges from 6 to 20 words. - It is appropriate to **monitor language development** in primary care rather than immediate referral, as language acquisition varies among children. *Fine motor delay is present and occupational therapy assessment is needed* - The ability to **scribble with a crayon** and **feed himself with a spoon** are consistent with typical fine motor skills expected around **18-21 months** of age. - There is no indication of a specific **fine motor delay** requiring an occupational therapy assessment at this stage given his age-appropriate performance.
