The Human Lifecycle. Normal behavior and typical behavior anomalies in different age groups

Case study

v  A17-year-old boy with a history of major depressive disorder (MDD) comes to your office for a routine visit. When you walk into the examining room, you notice that the boy is sitting slumped forward with his head bent down. He does not make eye contact and says nothing. You suspect that he is having a recurrence of depressive symptoms and are concerned about his risk for suicide.

Which of the following statements regarding depression and suicide in adolescents is true?

(A) Rates of suicidal behavior are similar in adolescent girls and boys.

(B) More girls than boys commit suicide.

(C) Suicide is a considerable risk in depressed adolescents and should be specifically addressed during an interview.

(D) A prior suicide attempt does not increase an adolescent’s risk of a subsequent one.

(E) The adolescent suicide rate has remained stable over the past few decades.

Answer:

(C) Suicide is a considerable risk in depressed adolescents, and should be specifically addressed during an interview with a patient who appears depressed or agitated or has a history of a suicide attempt. Surveys of adolescents in the general community have estimated that approximately 9% of adolescents have attempted suicide at least once in their lives. Among adolescents with known psychiatric disorders, the rate is much higher. More girls than boys demonstrate suicidal behavior, but nearly five times more teenage boys successfully commit suicide than do teenage girls, because boys more frequently use guns and violent methods to attempt suicide. History of a prior suicide attempt is an important risk factor for suicide in all age groups; the majority of those who successfully complete suicide have attempted suicide in the past. The adolescent suicide rate has increased substantially during the past few decades.

Case study

v  A 6-month-old girl is brought in by her grandmother for a routine visit. The physical examination is normal except that the baby has not gained weight as expected. As of earlier visits, the baby had been gaining weight appropriately. The grandmother reports that the baby likes to eat and is generally happy and playful. On further questioning, the grandmother describes chaotic mealtimes at home and says that the baby drools more than usual.

 1. Which of the following DSM-IV-TR eating disorders is the most likely diagnosis?

(A) anorexia nervosa

(B) bulimia nervosa

(C) pica

(D) rumination disorder

(E) feeding disorder of infancy or early childhood

2. Which of the following tests in this case would be most helpful in making the diagnosis?

(A) serum lead level

(B) calculation of the percentage of expected weight that the child’s weight is

(C) 24-hour video monitoring

(D) complete blood count (CBC)

(E) esophageal pH measurement

Answers

1. (D) The most likely diagnosis is rumination disorder, in which there is repeated regurgitation and re-chewing of food for a period of at least 1 month following a period of normal functioning. Rumination disorder is often seen in infants who have a variety of caretakers in an unstable environment. The drooling exhibited by this baby is most likely the milk or food that has been regurgitated. Lack of appropriate weight gain is typical when the baby does not re-swallow the food. Its unusual for a baby suffering from anorexia nervosa because she likes to eat and hardly does display fears. Similarly, she is not suffering from bulimia nervosa because much older children display episodes of binge eating with compensatory behavior, such as self-induced vomiting or misuse of laxatives. A diagnosis of pica would require that the baby persistently eat nonnutritive substances such as dirt, plaster, hair, bugs, or pebbles. A diagnosis of feeding disorder of infancy or early childhood is not appropriate because the baby’s disturbance is better accounted for by a diagnosis of rumination disorder.

2.  (E) To confirm the diagnosis of rumination disorder, an associated gastrointestinal or other general medical condition, such as esophageal reflux, must be ruled out. Esophageal pH measurement indicates if acidic gastric contents move into the esophagus during periods when the infant is not eating or actively regurgitating, as occurs in esophageal reflux. Measurement of the serum lead level is appropriate when pica is suspected, because old paints may contain lead, which can cause significant neurologic problems when ingested. Calculating the percentage of expected weight represented by the infant’s current weight would be required for a diagnosis of anorexia nervosa (85% or less) but is not a criterion for rumination disorder. Twenty-four-hour video monitoring would greatly aid in assessing the baby’s behavior and the context in which the disturbance occurs, but would not rule out a gastrointestinal condition as the cause of this problem. Results of a CBC would not be helpful in determining the diagnosis.

• Prenatal live events are important for the physical and mental health of the infant:

1.      Discuss why is so important the pregnant mother relationship with ‘would be’ baby (featus)?

• There are interesting experiments showing that male offspring of rats shows less masculine adult behavior if they are not properly exposed in proper time and of proper amount to androgen hormones (‘fetal androgen flush’) - hormones are produced by the embryo. The rat’s mother also produces hormones, which reach the developing embryo, therefore maternal stress has also long lasting effects, and this happens once the embryo rat exposed to stress through increased maternal corticosteroid excretion.

2.      Hormonal balances affecting fetal androgen production will determine the adult’s normal sexual behavior. This hormonal flush will determine the ‘wiring’ the brain of the adult.

3.      Bonding between mother and child depends on brain produced oxytocine and vasopressin hormones. Both hormones are released in ample during delivery and breast-feeding. Later in our life any bonding also escorted with brain vasopressin and oxytocine release while we are shaking hands, touching each other, patting each other shoulders. This is how friendships starts and strong solidarity established and why we feel so good meanwhile (at lest researchers say so)

·         The Birth: the fact is that number of cesarean section is increasing. (up to 23% of all birth) worldwide. This also includes that the next delivery will be also cesarean

·         Premature birth; infant mortality

1.      We are talking about premature birth in case shorter that than 37 weeks pregnancy

2.      It is a serious problem, because of 12% of all birth’s is premature (less than 37 weeks)

3.      It is also important to acknowledge that 2% of deliveries are less than 32 weeks

4.      While some countries of low birth rate in EU are offering good delivery services, even in the USA there is a total lack of free prenatal care

5.      In Afro American population of developed countries twice as many baby born prematurely and die in the first year of life

6.      It is a strong worldwide tendency of increasing maternal age

a.       It will result in increasing numbers of fertility treatment

b.      Increasing age of mothers may result in birth of premature low weight babies

7.      Do remember that infant death rate per 1000 live birth is 7

a.       This varies at least 10 fold depending on availability of good maternal (and infant) care

            Postpartum pathologic maternal reactions:

1.      The mother is seemingly not happy to have a baby. This is transient, and later she will show normal maternal behavior:  ‘postpartum blues’ ‘baby blues’ = last only for few days; spontaneous resolution

2.      Mood disorders of the mother frequently start around delivery = they last  for 1 year = medical condition which needs treatment. Prevalence 5-10%. The baby usually shows ‘failure to thrive’

3.      Mixed (schizo-affectiv) brief psychosis: be aware of imperative hallucinations = DSM-IVR ‘brief psychotic disorder with postpartum onset’. Begins in the postpartum month and last for up to 1 month

What do we observe when the baby grows?

Developmental spheres: Motor, Social and Verbal

1. Motor: means how the baby learn to move:

from cephalad – to caudad: (from head to the legs) – the baby will move the head first, to the direction she looks

from central – to peripheral direction; the baby will move the shoulder, trunk first and move the hands with mass movements before learn to use the hand and finally the fine finger movements

2. Social: when the baby discovers the world

           

from self (involvement) to (interaction with) others direction; the baby first is engaged with suckling, enjoying comforts, sleeping, being taken care etc and later slowly learns to perceive others, learn the mother, learn whom to smile, how to play, how to engage with others. At the beginning the baby cant perceive the world as a different entity, she shall learn that there is a difference between her experiencing her body as part of her self and learn that there is a world out there -  this takes years of refinement

3. Verbal/Cognitive

                       

from understanding to expressing

What we shall observe:

Developmental delay

Regression

Social & school impairment

Development Theories

(Thomas & Chess) infants have typical character traits, which are persistent at least the first 25 years of life in

                        activity level               

reactivity to stimuli

                        cyclic behavior                       

reactions to people

                        mood                          

distractibility

                        attention span

Temperament Categories:

                       

                        Easy children

                        Difficult children

                        Slow-to-warm-up children

Erik Erikson

Critical periods for the achievement of social objectives

Specific goals has to be achieved at specific age

If this is not successful at specific age, later the person will have difficulties to achieve it at all

E.g. Conflict of basic trust versus mistrust:

If the child does not learn trust others at age of 1, throughout his life this person will feel vulnerability in social interactions

Jean Piaget

Each age has typical cognitive & learning capability

The learning & cognitive capability determined by the neurological maturing process of the brain

The cognitive & learning capability typically NOT related with innate potentials but task have to be learned at a specific age

Margaret Mahler

Development = sequential process of separation from the mother

Success of this process will lead to INDIVIDUATION

Only successful individuation can lead to trusting and emotionally mature relationships

Sigmund Freud (pleasure stages)

Oral (the baby absorbed in suckling and feeding)

Anal (the child learns to use the toilet)

(Latency)

Genital (mature adult)

The infancy:  Definition: from birth to 18 months (up to 3 years here)

1. Bound formation (attachment) = process
2. First month: “normal autistic” phase
3. Social smile: appears @ 2 – 4 month (but: reflexive smile present at birth)
4. Stranger anxiety: 7-11 month
5. Object permanence: (Piaget) knows objects exist even if the are not visible at 1 year
6. Separation anxiety: at 1 year
7. Persistent separation = failure to thrive

Harlow’s experiment: absent normal maternal and social environment - if the monkey babies were longer than 6 month separated from the mother, adult monkey  (male monkey more vulnerable) will show irreversible behavior changes and unable show normal social and maternal behavior

Hospitalism (Rene Spitz) /institutionalization syndrome: for those babies and children who are growing up in institutions, there is a high mortality. Abusive or distant emotional relationship with the child of insensitive family environment leads similar symptoms

The result of grossly negligent or abusive or insensitive care = reactive attachment disorder of infancy or early childhood (DSM IVR)

Inhibited form (autism)

Disinhibited form (Cuddles everyone indiscriminately)

The normal MOTORIC development in infancy

Normal Neurologic reflexes of the Infant

Rooting

Sucking

Palmar grasp

Moro

Babinski

0-2 month:       follows objects with the eyes

lifts head when prone

2-3 month:       lifts shoulders when prone

4-6 month:       rolls over

reaches for objects

holds sitting position unassisted (6)

7-11 moth:       Crawls on hands and knees

pulls self up to stand (10)

pincer grasp

transfers objects from hand to hand

12-15 month:   walks unassisted

1.5y                 stacks 3 blocks

Throws ball

Climbs stars one foot at a time

2y                    stacks 6 blocks

Kicks ball

Undress

Use spoon & fork

3y                    stacks 9 blocks

Rides tricycle

Uses scissors

Dress herself assisted

Climbs stairs with alternate feet

Normal SOCIAL development in infancy

O-2 month       comforted by a voice / being picked up

2-3 month        social smile

4-6 month        recognizes people

Attachment formation

7-11 month      stranger anxiety

Use of gestures

12-15 month    Object permanence

Separation anxiety

1.5 year                       rapprochements (re-approach-ment – the child runs from/to mother)

2 year              parallel play

negativity = NO period

3 year              Gender identity

Toilet training

Tolerate separation

Verbal/Cognitive development in infancy

0-2 month        cries of hunger & discomfort

2-3 month        vocalization @ human attention (coos)

4-6 month        repeats single sounds over & over (babble)

7-11 month      responds own name/single instructions

12-15 month    first words

1.5 years          10 words usage, say own name, scribbles on paper

2 years             250 words usage, 2 word sentences, names body parts, uses pronouns

3 years             complete sentences, identifies some colors, copies a circle

    

The 3 years old child

The autonomy (Erickson) (tolerates separation a while)

Gender identity

The pathology:

School refusal

Encopresis; enuresis @ least 4-5 y olds with no control

Gender identity disorder

Preschool age = 3 to 6 years

1. Attachment
2. Maternal love is mature
3. Attachment & separation
1. Sibling rivalry
2. No adult type sense of right and wrong
3. No sharp line between fantasy and reality (magical thinking)
4. Strong fear of bodily injury
5. Regression
4. Motor development @ preschool age
1. 4 years: simple drawing of a person
2. Able to use garments with buttons and zippers
3. Combs hairs, brushes teeth
4. Hops one foot
5. Throws a ball
6. 5 y draws person in details
7. Skips using alternate feet
8. 6 y ties solaces
9. Rides bicycle

5. Social development @ preschool age
1. 4 years over concern about illness & injury
2. Curiosity about bodily functions
3. Nightmares & phobias
4. Imaginary companions
5. 5 y cooperative play
6. Affection seeking toward opposite-sex parents
7. 6 years moral emerges, conscience, superego
8. Begins to understand finality and death
9. Separation anxiety forms fear of parents death

6. Verbal/cognitive development @ preschool age

a.       4 years:

1.      Good verbal self expression

2.      Copies simple X shape with pencil

b.      5 years: copies square

c.                   Six years:  

1.      Copies triangle

2.      Begins to read

3.      Writes print letters

School age = (7-11 y)

Erickson: industry versus inferiority: industrialize your skills otherwise face with inferiority from that point of your life

Dormant sexuality = the ‘latency’

Mastering logical thought, reasoning and learning = concrete operations (Piaget)

Understand ‘conservation' (e.g . conservation of liquid, - irrespectively they shape containers with same volume of space can contain the same volume  of  liquid)

Multiple role models

Sense of competence

Peer relationships with same sex

Group formation

                        Empathy and morality

Internalize sense wrong & right

Rule consciousness

Understanding death

Adolescence (11-20y)

Early adolescence (11-14y) = puberty

                        Learns social responsibility, autonomy, principles

Middle adolescence (15-17y)

Preoccupied with body image and popularity (fashion)

Challenge rules

Feeling of invulneralibility & risk seeking behavior

Late adolescence (18-20y)

Identity crisis

Successful resolution = increased morale, ethics and self-control

Unsuccessful resolution: role confusion (abnormal behavior: e.g. criminality, drug abuse, cults)

Formal operations (abstract, hypothetical formal reasoning)

Crushes: fe.g. elling for a rock star

Mental disorders of childhood

DSM-IVR about childhood disorders

Personality disorders can NOT be diagnosed in children

Otherwise same diagnostic categories as adults (e.g. anxiety disorder, PTSD, mood disorders, schizophrenia) + they are specific childhood disorders

Pervasive developmental disorders (PDDs) (63/10.000)

a.       Failure to acquire/loss of social interactions and language/communication skill

b.      Restricted range of interest

c.       Repetitive behavior

d.      Clumsy motor coordination

           

Types:

1.      Autistic disorder

2.      Asperger’s disorder

3.      Rett’s Syndrome

4.      Childhood disintegrative disorder

Autistic disorder 

·         Manifest before age 3

·         Prevalence: 17/10,000

·         Deficit in socialization

·         Deficit in language & communication

·         Deficient social relations (even with parents)

·         Do not play with toys

·         Active resistance to any alterations in their environment, even to change dress

·         Repetitive behavior - Inflicted self injuries (bang head to wall)

·         Exceptionally some with savant skills (verbatim means learned person; a scholar. An idiot savant: a mentally retarded person who exhibits exceptional skill or brilliance in some limited field (as mathematics or music)

·         25-75 % mentally retarded

·         5x more common in boys

·         Suggested biological etiology

o   high concordance level @ monozygotic twins (3x)

o   frequent @ siblings of autistics

o   chromosome 15, 7q, 2q, 16p

o   suggested perinatal complication

·         25% has epileptic seizures

·         proposed role of DTP (diphteria; tetanus; pertussis) MMR (measles; mumps; rubella) immunization was not supported by large studies

Asperger’s disorder

                       

·         mild form of autism

·         difficulty in social relationships

·         repetitive behavior

·         obsessions (OCD) to memorize meaningless data

·         cognitive development NORMAL

·         NO developmental delay in language

·         but: significantly impaired conversational language

Rett’s disorder

·         Definition: diminished social, verbal & cognitive development after 4 years of normal functioning.

·         Typical stereotyped hand wringing movements

·         Breathing problems

·         Mental retardation

·         Ataxia & other psychomotor abnormalities

·         Declining motor skill

·         Tendency of social skill slightly improving at growing age

·         X-linked disease with locus maps to Wq28

·         Boys die early with this anomaly, therefore almost exclusively seen by girls

           

Childhood disintegrative disorder

Diminished social, verbal, cognitive and motor development following 2-10 years of normal functioning

Mental retardation: Definition: the child’s intellectual functioning is significantly below that expected for her age (oligophernia)

Down syndrome

95%: 21 chromosome trisomy caused by meiotic nondisjunction

4%: translocation and fusion of chromosomes 21 and 13, 14, 15

1% mosaicism caused by mitotic non-disjunction

Clinical symptoms:

§  (bear cub appearance)

§  Affect both sexes

§  Single palmar crease (monkey crease)

§  Protruding tongue

§  Flat facies

§  Epicanthal folds

§  Small ears

§  Hypotonia

§  Thick neck

§  Premature aging

§  Frequent Alzheimer disease

Fragile X syndrome (FXS)

Ø  Single gene abnormality on X chromosome Xq27 site

Ø  Affect in both sexes

Ø  Males more severely affected

Ø  Clinical symptoms:

§  Delayed cognitive functions

§  Behavior problems

§  Hyperactivity

§  Stereotyp movements (e.g. hand flapping)

§  Hyperextensible joints

§  Large ears

§  Elongated face

§  Postbubertal enlargement of testes

Other causes of mental retardation:

Ø  Fetal damage

Ø  Pre & postnatal infections

Ø  Rubella

Ø  Toxoplasma

Ø  Cytomegalo virus

Ø  Maternal substance abuse (e.g. alcoholic embriopathy)

Ø  Unknown causes

Ø  Autism

Ø  Neurological disorders

Ø  Seizures

Ø  Hearing and visual deficit

Ø  Storage diseases

Classification of mental retardations: (Wechsler test)

Mild                 IQ 50-69

Moderate         IQ 35-49

Severe              IQ below 35

Disruptive behavior disorders

1.      Conduct disorder

2.      Oppositional defiant disorder

Conduct disorder:

Behavior significantly violates social norms e.g.

·         Torturing animals or other children

·         truancy

·         Stealing

·         Setting fire

Oppositional defiant disorder:

·         Defiant

·         Argumentative

·         Resentful

·         Noncompliant

In general Disruptive behavior disorders are

·         More common in boys

·         Not associated with mental retardation

·         Prevalence 2-16%

·         In the history relatives also more likely to show

Antisocial behavior

Mood disorders

Substance abuse

Marital discord

History of child abuse

Prognosis: most cases improve. If problem persist after age 18 = antisocial personality disorder

Tourette’s disorder

            Symptoms are:

Involuntary movements

Vocalizations (tics)

Coprolalia

The condition is more common in boys

Start at age 7

Frequently misdiagnosed

Caused by dysfunctional dopamine regulation in caudatum

Therapy:

Haloperidol (Haldol)

Pimozide

Risperidone (Risperdal)

ADHD (attention deficit hyperactivity disorder)

1.      Predominantly inattentive type

2.      Predominantly hyperactive type

3.      Combined type

Etiology: unknown (MBD?)

Th:

Ritalin (methylphenidae)

Desedrine (dextroamphetamine)

Prognosis: improves during aging

Separation anxiety disorder

E.g. school phobia or school refusal

Overwhelming fear of loss of major attachment figure

Parents also show overwhelming concern about child’s well being

Affects 4% of school-age children

Usually start at age 7 – 8

Late onset has poor prognosis

Anxiety disorder/agoraphobia in adulthood

Selective mutism

Rare

The child speaks in one social situation but not in another

Onset @ age 6

Poor prognosis if exist after age 10

The Adulthood

Early adulthood:          20-40y

Middle Adulthood:      40-65 y

Old age:                       65 y & older

Sequence of successful reappraisal of objectives, desires, and values until death

Unsolved life transitions prone the person vulnerable to mental or physical illness

Demographics:

The Marriage:

Married man lives longer than non married and have less health problem

Average age for (first) marriage 25 for women 27 for man

The Family

The nuclear family

The extended family

Rise a child to age 17: 100.000 USD

With post secondary schooling: 200.000 USD

Divorce

½ of marriages end with divorce:

High risk: 20% higher if one partner physician

Female psychiater if married at the university years

Short courtship

Premarital pregnancy

Prior divorce in the family

Absence of family support

Difference in religion or socioeconomic background

                       

Early adulthood: 20 – 40 y

Intimacy versus isolation (Erickson)

Intimacy without loss off sense of identity

Middle adulthood

Generativity versus stagnation (Erickson)

Money, power and authority

Responsibility for the older and the younger generation = sandwich generation

Midlife crisis

Climacterium/menopause

The baby boomers

Old age (65 & above) (senior or mature citizens)

Above 85 – ‘old-old’ This is the fastest growing population segment in certain countries

15% of the population soon will be above 65y

Loss of social status

Loss of spouse etc.

Declination in health and strength

Ego integrity versus despair (Erickson)

Achievable average life expectancy: 76 y

Greatly varies with gender & ethnicity

Longest life: Chinese American women

Shortest life: Afro-American men

Long living people:

Female

Family history

Marriage

Continued activity

Previous work satisfaction

Advanced education

Dementia is NOT part of aging

Dementia is increasing with aging

10% of elderly affected

Risk of

Alzheimer

Depression (pseudo dementia)

Suicide

Sleep disorders

Benzodiazepine (alcohol) abuse

Being Abused

Biology of aging:        

Depression                               Norepineprine  ß         

Depression                               Dopamine        ß         

Anxiety                                    GABA ß                     

Dementia                                 Acetylcholine  ß         

Other psychiatric symptoms    MAO                         

Dying (Kubler-Ross classification is the most descriptive)

1.      Denial

2.      Anger

3.      Bargaining

4.      Acceptance

The Grief reactions

Normal grief = bereavement

Severe reaction, severe symptoms for 2 month

Shock and denial (short)

Sadness, grief etc for 1-2 y

Anniversary reaction

Illusions

Support needed and benzodiazepinses, family doctor

Abnormal grief = Depression

Severe reaction

Shock and denial (long lasting)

Persisting even increasing bereavement

Hallucinations and delusions

Significant sleep disturbance

Intense feeling of guilt

Suicide

Severe symptoms for more than 2 month

Antipsychotics, antidepressants, ECT, psychiater

Case studies

v  A schoolteacher refers an 8-year-old boy to you because he has been complaining of stomachaches every morning in school. On interviewing the boy’s mother, you learn that he does not like to go to school, insists on coming home immediately after school each day, and sleeps in his parents’ bed at night. The mother denies other complaints.

1. Which of the following is the most likely diagnosis?

(A) social phobia

(B) posttraumatic stress disorder (PTSD)

(C) separation anxiety disorder

(D) reactive attachment disorder of early childhood

(E) specific phobia

2. This boy’s stomachaches are an example of which of the following?

(A) coprolalia

(B) anhedonia

(C) reaction formation

(D) coprophagia

(E) somatization

Answers

1. (C) This boy’s behavior and symptoms are most consistent with separation anxiety disorder, characterized by developmentally inappropriate and excessive anxiety concerning separation from the home or from those to whom the individual is attached. Consistent with this diagnosis, the boy does not like to go to school, comes home immediately after school, sleeps in his parents’ bed at night, and has repeated physical symptoms when at school.

The boy does not suffer from social phobia disorder because he does not have a marked and persistent fear of a social or performance situation with exposure causing intense anxiety, expressed as a tantrum or a panic attack.The boy is not suffering from PTSD because there is no evidence of a traumatic event that is persistently re-experienced and has caused symptoms of increased arousal and avoidance of associated stimuli. For a diagnosis of reactive attachment disorder of infancy or early childhood, the boy would need to have suffered markedly disturbed social relatedness, in most contexts, beginning before the age of 5. Finally, a diagnosis of specific phobia would require the display of marked and persistent fear cued by the presence of anticipation of a specific object or situation, expressed as a tantrum or panic attack.

2. (E)  Somatization is a defense mechanism in which emotional concerns are manifested as

physical symptoms. Coprolalia is the repetitive speaking of obscene words, seen in severe cases of Tourette disorder. Anhedonia is the lack of enjoyable, seen in MDD. Reaction formation is a defense mechanism in which an unacceptable impulse is transformed into its opposite. Coprophagia is the eating of feces.

v  A 5-year-old boy is brought to the emergency department because he is frantically trying to run away from lions that he says are chasing him. He says that when he sees the lions he has to jump out of their way or else they will attack him.

1. Which of the following disorders is the most likely?

(A) schizophrenia

(B) panic disorder

(C) autistic disorder

(D) moderate mental retardation

(E) substance-induced psychotic disorder

2. Which of the following is the most common psychiatric emergency in the child and adolescent population?

(A) psychotic behavior

(B) assaultive behavior

(C) suicidal behavior

(D) homicidal behavior

(E) sexually inappropriate behavior

Answers

1. (E) Substance-induced psychotic disorder is the most common cause of florid visual hallucinations in a child. The child may have ingested prescription drugs, illicit drugs, over-the counter medications, or a household agent.

Schizophrenia rarely presents in young children. When it does, it is much more likely to present with auditory hallucinations than with visual hallucinations. Hallucinations do not occur in panic disorder, autistic disorder, or mental retardation.

2. (C) Suicidal behavior is the most common psychiatric emergency in children and adolescents. Psychotic behavior, particularly assaultive behavior, and homicidal behavior are less common emergencies. Sexually inappropriate behavior alone is rarely an emergency.

v  Her mother brings a 24-month-old girl to the clinic for a routine visit. The mother tells you that the girl has not spoken her first clear word yet, at times seems not to understand what people say to her, and does not play with her 3-year-old brother. The mother also tells you that her daughter seems clumsy and has started to make odd repetitive movements with her hands. According to the girl’s chart, she had a normal head circumference at birth, at 6 months, and at 12 months, and had seemed to be developing normally. On physical examination, you note that the rate of head growth has slowed.

1. Which of the following pervasive developmental disorders is the most appropriate diagnosis?

(A) autistic disorder

(B) Rett disorder

(C) childhood disintegrative disorder

(D) Asperger disorder

(E) pervasive developmental disorder not otherwise specified

2. Which of the following statements best describes this girl’s disorder?

(A) It is seen exclusively in girls.

(B) There is never an Axis II diagnosis.

(C) There are no clear characteristic chromosomal abnormalities associated with the disorder.

(D) There are familial clusters of the disorder.

(E) It is the most common of the pervasive developmental disorders.

Answers

1. (B) This girl’s history and presentation are consistent with Rett disorder, which is characterized by normal prenatal and perinatal development, normal head circumference at birth, and normal psychomotor development through the first 5 months of life. Between the ages of 5 and 48 months, there is deceleration of head growth, loss of hand skills with development of stereotyped hand movements such as hand wringing, loss of social interaction (which may improve later), appearance of poorly coordinated gait or trunk movements, and severely impaired expressive and receptive language development with severe psychomotor retardation. Autistic disorder and pervasive developmental disorder, not otherwise specified, are not appropriate diagnoses because this girl’s presentation is better accounted for by

Rett disorder. Children with childhood disintegrative disorder do not develop normally for at least 2 years after birth. Children with Asperger disorder do not show delay in language development (e.g., single words are used by the age of 2).

2. (A) Rett disorder is the only DSM-IV-TR disorder that is seen only in girls. Children with Rett disorder commonly suffer from mental retardation, which is coded on Axis II. Although there are no clear characteristic laboratory findings associated with the disorder, there is a genetic test available. There are no known familial clusters of the disorder. Autistic disorder is the most common of the pervasive developmental disorders.

v  A 10-year-old girl who has recently been diagnosed with diabetes mellitus Type I is referred to you for an evaluation. You notice that she seems sad. After interviewing the girl and her parents, you determine that she meets DSM-IV-TR criteria for adjustment disorder with depressed mood.

1. Which of the following criteria for the diagnosis of adjustment disorder distinguishes it from MDD?

(A) Symptoms develop following an identifiable stressor.

(B) Symptoms develop within 3 months of the onset of the stressor.

(C) Symptoms do not persist for more than 6 months following termination of the stressor.

(D) Symptoms cause marked distress or significant impairment in functioning.

(E) Symptoms do not represent bereavement.

2. Approximately what percentage of children who are diagnosed with diabetes mellitus Type I develop adjustment disorder following their medical diagnosis?

(A) 1%

(B) 5%

(C) 10%

(D) 33%

(E) 75%

Answers

1. (C) By definition, symptoms of adjustment disorder do not last longer than 6 months after a stressor or the termination of its consequences.

If depressive symptoms persist, MDD may be diagnosed. In both adjustment disorder and MDD, symptoms may develop following a stressor, may develop within 3 months of the onset of a stressor, must cause marked distress or significant impairment in functioning, and must not represent bereavement.

2. (D) Following a diagnosis of diabetes mellitus Type I, approximately 33% of children develop symptoms of adjustment disorder.

v  A 9-year-old boy is referred to you for evaluation after increasingly disruptive behavior in school. The teachers report that at any time, without warning, the boy will make a disruptive sound or shout out in class. They describe him as polite and neat but restless and jumpy.

1. Which of the following is the most likely diagnosis?

(A) Oppositional defiant disorder

(B) Conduct disorder

(C) Separation anxiety disorder

(D) Panic disorder

(E) Tourette disorder

2. Which of the following medications is most appropriate?

(A) bupropion (Wellbutrin)

(B) paroxetine (Paxil)

(C) venlafaxine (Effexor)

(D) haloperidol (Haldol)

(E) clonidine (Catapres)

Answers

1. (E) Tourette disorder is the most likely diagnosis because the boy’s outbursts are consistent with vocal tics, and the report of “restless and jumpy” behavior is consistent with misinterpretation of motor tics. Tourette disorder most commonly develops in grade school-age boys, and the involuntary tics may be misinterpreted as purposefully disruptive behavior. Of note, there is frequent co-morbidity with ADHD. This boy does not suffer from oppositional defiant disorder or conduct disorder because he is polite and neat and does not display hostile, destructive, or angry behaviors. There is no evidence that this boy experiences distress and worry when separated from an important attachment figure as in separation anxiety disorder. The outbursts are not typical of panic disorder, in which there are discrete panic attacks, periods of intense fear, or discomfort with physical manifestations such as palpitations and subjective difficulty breathing.

2. (E) Clonidine has become the first-line treatment for Tourette disorder. It has a limited side effect profile and helps control symptoms of the two frequently associated comorbid disorders: ADHD and OCD. TCAs have been shown to be effective in the treatment of Tourette disorder, but other antidepressants such as bupropion, paroxetine, and venlafaxine are not known to be effective. High-potency antipsychotics such as haloperidol and pimozide were traditionally the first-line agents for Tourette disorder. The newer atypical antipsychotics, such as risperidone, are not known to be effective in treating the disorder.

v  An 8-year-old boy with a family history of tic disorders is referred to you for an evaluation of behavioral difficulties in school. His teachers report that he is unable to sit still, constantly fidgets, and is unable to complete class work because he is so easily distracted. The boy’s mother reports that he has always had a lot of energy. She says that preparing to leave for school in the morning is extremely difficult because of her son’s disorganization and forgetfulness. Otherwise, she has no complaints. She denies that her son produces any repetitive movements or sounds.

1. Which of the following is the most likely diagnosis?

(A) dementia

(B) conduct disorder

(C) oppositional defiant disorder

(D) attention deficit hyperactivity disorder (ADHD)

(E) disruptive behavior disorder not otherwise specified

2. Which of the following classes of medications is most likely to unmask an underlying predisposition to developing tics?

(A) stimulants

(B) selective serotonin reuptake inhibitors (SSRIs)

(C) monoamine oxidase inhibitors (MAOIs)

(D) D2 antagonists

(E) benzodiazepines

Answers

1. (D) This boy’s history is typical of ADHD, combined type. He is fidgety and distractible in school as well as at home, and this is interfering with his ability to function. Forgetfulness due to distractibility is commonly seen in ADHD and is not a sign of dementia. This boy does not display excessive aggression, destruction of property, deceitfulness, theft, or serious violations of rules, as seen in conduct disorder. His behaviors are not negativistic, hostile, or defiant, so he does not suffer from oppositional defiant disorder. Disruptive behavior disorder not otherwise specified is a diagnosis reserved for cases in which there are conduct or oppositional defiant behaviors that do not meet the full criteria for conduct disorder or oppositional defiant disorder but cause significant impairment.

2. (A) Stimulant medications have been associated with an increased risk of developing tics. In general, if a child suffers from tics or has a family history of tics, stimulant medications should be avoided and a TCA should be used to treat ADHD if necessary. SSRIs, MAOIs, D2 antagonists, and benzodiazepines are not known to exacerbate tics.

v  During a routine office visit, the mother of a 22-month old girl tells you that she is concerned about her daughter’s behavior. Since the birth of her son 4 months earlier, the mother states that her daughter is more irritable and angry. The mother is especially concerned that her daughter is aggressive and violent toward the baby.

1. Which of the following statements is the most appropriate response to this mother?

(A) “If you simply ignore your daughter’s behavior, it will pass.”

(B) “Your daughter’s behavior is normal for her age.”

(C) “Every day, schedule some time for you and your daughter to spend together without the baby.”

(D) “Explain to your daughter that the baby needs more attention that she does right now.”

(E) “Your daughter must be precocious since the terrible twos are starting early.”

2. At 22 months of age, this girl should be able to do which of the following?

(A) copy a circle

(B) copy a square

(C) identify her left hand

(D) tell her age and gender

(E) ride a tricycle

Answers

1. (C) Since the birth of the baby, the parents have probably spent a lot of time tending to the new baby’s needs and paying less attention to their daughter. The girl may feel rejected, jealous, and angry. The most helpful approach is for the mother to spend time alone with her daughter every day, giving her undivided attention, and showing her that she is still loved and wanted. The girl is unlikely to be reassured by a single discussion about how the baby needs more attention than she does. Being consistently irritable, angry, and violent is not normal behavior at 20 months or at 24 months. The girl’s behavior should not be ignored.

2. (A) A developmentally normal child can copy a circle at the age of 2. She can tell her age and gender and ride a tricycle at age 3. She can copy a square and can identify her left hand at age 5.

v  A 4-year-old boy is referred to you for evaluation because he has not started talking. He appears healthy and well-cared for. He readily comes with you to the examining room. In your office, he notices a windup toy and immediately becomes engrossed in winding it up, watching it move around until it winds down, and winding it up again. After about 10 minutes, you attempt to take the toy from him and he becomes extremely upset, making an insistent, piercing cry.

1. Which of the following is the most likely diagnosis?

(A) Oppositional defiant disorder

(B) Conduct disorder

(C) Separation anxiety disorder

(D) Autistic disorder

(E) Selective mutism

2. Which of the following qualities is associated with a more favorable prognosis for children similar to this boy?

(A) Easily toilet trained

(B) Organized in play

(C) Interested in mechanical toys

(D) Able to converse

(E) Able to dance to a beat

Answers

1. (D) This boy’s behavior is characteristic of autistic disorder. He suffers from impaired social interactions and attachments, restricted interests and behaviors, and impaired communication. He does not object to going with a stranger to the examining room, does not interact with the physician, becomes preoccupied with a toy to an abnormal degree, and screams when the toy is taken away. He is not primarily negativistic and hostile as in oppositional defiant disorder. He is not aggressive, destructive, deceitful, or in violation of rules, as in conduct disorder. He does not become upset when separated from his mother, as in separation anxiety disorder.

2. (D) Children with autistic disorder have more favorable prognoses if they are able to converse meaningfully rather than unable to interact positively with others. They are often easily toilet trained, often enjoy mechanical toys, are rigidly organized in their play, and may become preoccupied with the rhythm or beat of music. These latter characteristics are not associated with a good prognosis.

v  The mother of one of your 4-year-old patients calls and asks you for advice. She says that her son has been stealing toys from other children at school and bringing them home with him. Which of the following suggestions is most appropriate?

(A) The mother should return the toys herself and buy her son similar toys.

(B) The mother should tell her son that if he stops stealing, she will give him a reward each week.

(C) The mother should point out to her son that he is stealing and punish him for it.

(D) The mother should help her son return the toys.

(E) The mother should ignore the entire situation because her son’s behavior is part of a developmental phase that will pass.

Answer

(D) The most appropriate advice is that the mother should help her son return the toys. The boy is in a developmental period when his conscience is being established, and the parental model is important. The parent can show the child how to act responsibly by helping him return the toys himself. At the age of 4, a child cannot adequately grasp the abstract concept of stealing, so punishment is not helpful. His sense of time is limited, so he cannot integrate the idea of a reward after a week.

v  A 4-year-old boy whose mother had rubella during her pregnancy is brought to the clinic for a routine visit. The physical and laboratory examinations are normal. The highest risk of physical and/or mental defects in the fetus as a result of maternal rubella infection occurs during which month of the pregnancy?

(A) first

(B) third

(C) fifth

(D) seventh

(E) ninth

(A) When the mother is infected with rubella during the first month of the pregnancy, the risk of congenital defects is 50%. The risk of defects decreases inversely with the duration of pregnancy at the time of disease.