THG04-001
A 15-year-old boy is brought with complaints of poor appetite, losing weight, feeling hopeless and down most of the time, loss of interest in school and other activities along with insomnia for the past 1 month. He does not have any substance use.
a. What is the most probable diagnosis here?
b. What medical conditions should be ruled out here?
c. What are the only two drugs that are approved by the Food and Drug Administration (FDA) for treatment of this condition in youth?
d. What is the screening interview for a rapid psychosocial history?
Answer
- a. Major depressive disorder.
- b. Hypothyroidism, autoimmune encephalitis, brain tumors, chronic fatigue syndrome, Wilson disease, and systemic infections/autoimmune disorders.
- c. Fluoxetine (≥8 years) and Escitalopram (≥12 years).
- d. HEADSS / HEEADSSS assessment: Home, Education/Employment, Eating, Activities, Drugs, Sexuality, Suicide/Depression, Safety.
THG04-002
A 12-year-old girl presented with 3–4 years of anxiety symptoms. She was worried that her neighbors will hurt her, afraid to go out because of dogs, and afraid to go out in dark. She has on and off panic symptoms, sleep disturbances, hyperventilation, and vague headache unexplained medically.
a. What is the possible diagnosis?
b. What medical conditions should a pediatrician rule out?
c. What are the best treatment methods?
Answer
- a. Generalized anxiety disorder (GAD).
- b. Hyperthyroidism, pheochromocytoma, systemic lupus erythematosus (SLE), cardiac arrhythmias, asthma, and autoimmune encephalitis.
- c. Cognitive behavioral therapy (CBT), Selective Serotonin Reuptake Inhibitors (SSRIs, e.g., fluoxetine, sertraline), and Buspirone.
THG04-003
A 12-year-old girl has come with 6 months history of weight loss. She has lost 19 kg over this period. No medical causes were found in extensive evaluation from multidisciplinary medical team. Parents report avoidance of food especially rice and prefers vegetables and involves in increased exercising behaviors. On psychological evaluation, she denies any cognition related to abnormal body image and denies any fear of weight gain. However, parents report significant anxiety and externalizing behaviors on forcing meal.
a. What is the diagnosis?
b. What is the differential diagnosis?
c. What are the two types of this disorder?
d. List some complications of this disorder.
e. What are the symptoms and signs required for admitting this girl?
Answer
- a. Anorexia nervosa (or Avoidant Restrictive Food Intake Disorder [ARFID]).
- b. Avoidant/Restrictive Food Intake Disorder (ARFID), Obsessive Compulsive Disorder (OCD), Major Depressive Disorder, Hyperthyroidism, Inflammatory Bowel Disease (IBD), Celiac disease, and Malignancy.
- c. Restricting type and Binge-eating/purging type.
- d. Complications:
- Cardiac: Sinus bradycardia, hypotension, reduced left ventricular mass/contractility, prolonged QTc, arrhythmias (leading medical cause of death), and refeeding syndrome.
- Endocrine/Metabolic: Hypothalamic amenorrhea/hypogonadism, sick euthyroid syndrome, osteopenia/osteoporosis, hypothermia.
- Hematologic/GI: Cytopenias, delayed gastric emptying, severe constipation.
- e. Admission criteria:
- Heart rate <50 bpm, blood pressure <80/50 mm Hg, postural hypotension (>10 mm Hg drop or >25 bpm increase).
- Cardiac arrhythmia or prolonged QTc.
- Hypokalemia, hypophosphatemia, hypoglycemia, hypomagnesemia.
- Severe hypothermia (<36.1°C).
- Body weight <75–80% of median expected for age/height.
- Acute food refusal, severe dehydration, hepatic/renal impairment, or acute suicidal ideation.
THG04-004
A 6-year-old boy is brought with complaints that he does not sit in the class or home, always keeps running around, talks too much, not able to sustain attention on any work given, often easily distracted and very forgetful for the past 8 months. He has been diagnosed with attention deficit hyperactivity disorder (ADHD).
a. What are the diagnostic tools for ADHD and what is the tool for Indian children?
b. What is the differential diagnosis?
c. What are the treatment modalities available?
d. What should be ruled out before the treatment is started?
Answer
- a. Diagnostic tools: Vanderbilt ADHD Diagnostic Rating Scale, Conners Rating Scales (CRS-R), Child Behavior Checklist (CBCL). Validated Indian tool: INCLEN Diagnostic Tool for ADHD (INDT-ADHD).
- b. Hearing/visual impairment, specific learning disorders, sleep apnea/disorders, hyperthyroidism, lead toxicity, absence seizures, Fragile X syndrome, anxiety disorders, and response to psychosocial stress/abuse.
- c. Treatment modalities:
- Behavioral parent training (BPT) and classroom behavioral interventions.
- Pharmacotherapy: Stimulants (Methylphenidate) and non-stimulants (Atomoxetine, Clonidine, Guanfacine).
- Remedial education and sensory integration therapy.
- d. Personal or family history of sudden unexplained cardiac death, Wolff-Parkinson-White syndrome, hypertrophic cardiomyopathy, long QT syndrome, arrhythmias, syncope, hypertension, or active tic/psychiatric disorder.
THG04-005
A 15-year-old girl is brought by her mother with complaints of repetitive paroxysmal events for the past 6 months. She describes the events are variable in semiology but consist of sudden apparent loss of consciousness with fall. Family has also observed side to side jerking of head, tight eye closure, pelvic thrusting movements with deep open mouthed breathing during these episodes. She is a developmentally normal girl with no past history or family history of seizures. She is on 3 anti convulsants but mother feels there is no response to the drugs. Her physical examination including central nervous system (CNS) are normal. Further questioning reveals that her parents have been separated for a year.
a. What is the most likely diagnosis?
b. What are the risk factors for this condition?
c. What are the treatment options?
Answer
- a. Conversion disorder / Functional Neurological Symptom Disorder (Psychogenic Non-Epileptic Seizures [PNES]).
- b. Preexisting anxious/insecure temperament, family conflicts/parental separation, school stress, history of physical or emotional abuse, peer bullying, personal/family history of medical illness, and secondary gain.
- c. Treatment options:
- Clear and compassionate communication of the diagnosis (psychoeducation).
- Discontinuation/tapering of unnecessary antiepileptic drugs under neurology supervision.
- Cognitive Behavioral Therapy (CBT) and individual psychotherapy.
- Family counseling to address parental separation and avoid symptom reinforcement.
- Pharmacotherapy for coexisting depression or anxiety.
THG04-006
A 2-year-old boy child is brought with complaints of delay in language, not responding to being called, no interaction with family members or other children, only occasional eye contact. He has normal hearing and vision and motor development is within normal limits. On examining, you find him rocking himself in the chair and does not stop. He is also having echolalia. Mother describes he has tantrums if his routines are interchanged and does not like change in environment.
a. What is the most probable diagnosis?
b. What is the etiology of this condition?
c. What genetic test is done and list out some genetic syndromes that mimics this condition?
d. What are the comorbid conditions associated with it?
e. What are the screening tools for Indian children?
f. What are the diagnostic tools for Indian children?
Answer
- a. Autism Spectrum Disorder (ASD).
- b. Polygenic complex inheritance, advanced parental age (maternal/paternal), short interpregnancy interval, extreme prematurity/low birth weight, prenatal valproate exposure, and prenatal infections (CMV, rubella).
- c.
- Genetic test: Chromosomal Microarray (CMA), Fragile X testing (FMR1 repeat analysis), Whole Exome Sequencing.
- Syndromic mimics: Fragile X syndrome, Rett syndrome, Tuberous Sclerosis Complex, PTEN hamartoma syndrome, Angelman syndrome, Smith–Lemli–Opitz syndrome.
- d. Intellectual disability, expressive language disorder, ADHD, epilepsy, sleep disturbances, gastrointestinal issues (GERD, constipation), and anxiety disorders.
- e. Screening tools: Modified Checklist for Autism in Toddlers (M-CHAT-R/F), Social Communication Questionnaire (SCQ), Trivandrum Autism Behavior Checklist (TABC), Childhood Autism Rating Scale (CARS).
- f. Diagnostic tools: Indian Scale for Assessment of Autism (ISAA), INCLEN Diagnostic Tool for ASD (INDT-ASD), Autism Diagnostic Observation Schedule (ADOS-2), Autism Diagnostic Interview-Revised (ADI-R).
THG04-007
A 1.8-year-old boy with features of autistic spectrum disorder presents to your outpatient clinic for evaluation.
a. What is the differential diagnosis to be considered?
b. What key features should be noted in physical examination?
c. What are the indications for brain imaging in a child with autism?
d. What are the key components of treatment?
e. Mention the drug of choice when a child with autism spectrum disorder has the following features:
i. Maladaptive behavior / Severe irritability
ii. ADHD symptoms
iii. Anxiety / Depression
iv. Sleep disturbances
f. Name some schemes available for the welfare of people with autism.
Answer
- a. Global developmental delay / Intellectual disability, severe receptive-expressive language disorder, hearing impairment, severe psychosocial deprivation, ADHD, and Landau–Kleffner syndrome.
- b. Head circumference (macrocephaly/microcephaly), dysmorphic features, neurocutaneous markers (hypopigmented ash-leaf spots via Wood's lamp), neurological tone, reflexes, and joint hypermobility.
- c. Microcephaly or macrocephaly, developmental regression, focal neurological deficits, neurocutaneous markers, or refractory seizures.
- d. Applied Behavior Analysis (ABA), TEACCH program, Speech and Language Therapy, Occupational Therapy (sensory integration), augmentative and alternative communication (AAC), parent-mediated intervention (e.g. Early Start Denver Model).
- e.
- (i) Maladaptive behavior / Severe irritability: Risperidone (or Aripiprazole)
- (ii) ADHD symptoms: Methylphenidate
- (iii) Anxiety / Depression: Fluoxetine (SSRI)
- (iv) Sleep disturbances: Melatonin
- f. National Trust Schemes (Govt. of India):
- Niramaya: Health insurance scheme
- Aspiration: Early intervention and school readiness scheme
- Gyan Prabha: Scholarship scheme for vocational/higher education
- Samarth: Respite care scheme
THG04-008
A 6-year-old developmentally normal boy child is brought with complaints of sudden and recurrent movements such as eye blinking, jerking of neck, and repeating his words often. This occurs multiple times in a day and has been present for the past 1 year. There are no other associated complaints like fever or altered sensorium or any drug intake.
a. What is the most probable diagnosis?
b. What is the differential diagnosis?
c. What are the associated comorbidities?
d. What are the treatment modalities available?
Answer
- a. Tourette Disorder (Tourette Syndrome). (Presence of both multiple motor tics and vocal tics for >1 year).
- b. Transient tic disorder, motor stereotypies, OCD compulsions, Sydenham chorea, benign paroxysmal torticollis, Sandifer syndrome, and drug-induced tics (stimulants).
- c. ADHD (most common, ~60%), OCD (30–50%), anxiety disorders, specific learning disabilities, sleep problems, and depressive disorders.
- d.
- Behavioral therapy: Comprehensive Behavioral Intervention for Tics (CBIT), Habit Reversal Training (HRT).
- Pharmacotherapy: Alpha-2 adrenergic agonists (Clonidine, Guanfacine); atypical antipsychotics (Aripiprazole, Risperidone); dopamine receptor antagonists (Haloperidol, Pimozide).
- Psychoeducation and classroom accommodation.
THG04-009
A 9-month-old developmentally normal girl infant was brought to the emergency room with complaints that following crying, she suddenly stopped breathing for a few seconds and lips became blueish followed by a seizure-like movement for a few seconds and then became normal and started responding to the mother. She says that the baby has had previous episodes like this in the past 6 months but without the seizure-like movement. She is hemodynamically stable on examination without any other complaints and is very active now with all vitals stable.
a. What is the most probable diagnosis?
b. What is the differential diagnosis?
c. What are the types of this condition?
d. What is the management for this condition?
Answer
- a. Cyanotic Breath-Holding Spells (with reflex anoxic seizure/hypoxic convulsion).
- b. Epileptic seizures, prolonged QT syndrome/cardiac arrhythmias, orthostatic syncope, gastroesophageal reflux with laryngospasm, and central hypoventilation.
- c. Cyanotic spells (most common), Pallid spells (reflex anoxic seizures), and Mixed spells.
- d.
- Reassurance and parental education regarding the benign nature and self-limiting course.
- Advise parents not to reinforce tantrums or panic during episodes; place the child supine in a safe recovery position during an attack.
- Screen for and treat iron deficiency anemia with oral elemental iron therapy (significantly reduces attack frequency even without overt anemia).
THG04-010
A 7-year-old boy child is brought with complaints of losing temper easily, arguing often with elders, refuses to listen to anything that his parents or relatives tell, and very sensitive for the past 8 months. This has been causing distress to both him and the parents.
a. What is the diagnosis here?
b. How is this disorder classified?
c. What is the differential diagnosis?
d. What are the sequelae associated with this disorder?
e. What are the various treatment options available?
Answer
- a. Oppositional Defiant Disorder (ODD).
- b. Classification by Severity (DSM-5):
- Mild: Symptoms are confined to only one setting (e.g. at home, at school, with peers).
- Moderate: Symptoms are present in at least two settings.
- Severe: Symptoms are present in three or more settings.
- c. Conduct Disorder, ADHD, Intermittent Explosive Disorder, Disruptive Mood Dysregulation Disorder (DMDD), Major Depressive Disorder, and Bipolar Disorder.
- d. Progression to Conduct Disorder, Antisocial Personality Disorder, substance use disorder, school drop-out, delinquency, and poor peer relationships.
- e.
- Parent Training Programs: Parent Management Training (PMT), Incredible Years, Triple P (Positive Parenting Program).
- Child Psychotherapy: Cognitive Behavioral Therapy (CBT), problem-solving skills training, anger management.
- School interventions: Behavioral plans and classroom support.
- Pharmacotherapy: Treat coexisting ADHD (stimulants/atomoxetine) or mood dysregulation.
THG04-011
A 9-year-old boy is brought with complaints of difficulty in reading and writing for >2 years. In spite of sending him to various tuitions he is not able to keep up with his peers academically. He is a developmentally normal child with normal vision and hearing from a stable family.
a. What is the diagnosis of this child?
b. What are the possible comorbid conditions for this diagnosis?
c. Name any four psychometric tests used for assessment.
d. What interventions can be done for treatment?
e. What are the provisions and advocacies done for this condition by the Indian Government?
Answer
- a. Specific Learning Disorder (SLD) (Dyslexia / Dysgraphia).
- b. ADHD (most common, ~30–40%), developmental coordination disorder (dyspraxia), communication disorders, anxiety disorders, and depression.
- c.
- NIMHANS Index for Specific Learning Disabilities
- Malin’s Intelligence Scale for Indian Children (MISIC)
- Binet-Kamat Test of Intelligence (BKT)
- Grade Level Assessment Device (GLAD) / Diagnostic Test of Learning Disabilities (DTLD)
- d. Multisensory structured phonics instruction, individualized educational plan (IEP), remedial teaching, assistive technology (text-to-speech software, spell checkers), and psychological counseling.
- e. Recognized as a benchmark disability under the Rights of Persons with Disabilities (RPWD) Act, 2016.
- Provisions: Free education up to 18 years, extra compensatory time (20 min per hour of exam), provision of scribe/reader/computer, exemption from 2nd/3rd language, permission to use calculators, and examination concessions across state/central boards (CBSE/ICSE).