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. | Neurological conditions such as autoimmune encephalitis, brain tumors, chronic fatigue disorder, and infectious disorders. |
| c. | Fluoxetine and escitalopram. |
| d. | HEADSS—home, education, activity, drugs, sexuality, and suicide/depression. |
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. |
| b. | Hyperthyroidism, lupus, pheochromocytoma, and autoimmune encephalitis. |
| c. | Cognitive behavioral therapy (CBT), selective serotonin reuptake inhibitor (SSRI), 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. |
| b. | Avoidance restrictive food intake disorder (ARFID), obsessive compulsive disorder (OCD), and medical causes such as hyperthyroidism, malignancy, and inflammatory bowel disease. |
| c. | Binge-eating and restricting type. |
| d. | Cardiac complications—sinus bradycardia, hypotension, reduced myocardial contractility, refeeding syndrome, tachyarrhythmias (second cause of death after suicide), hypothalamic dysfunction induces problems in sleep, thermoregulation, endocrine function, reduced gonadal function, and decreased bone mineral density. |
| e. | Heart rate <50 beats/minute, arrhythmia, blood pressure <80/50 mm Hg, postural hypotension >10 mm Hg decrease or <25 beats/minute increase, hypokalemia, hypophosphatemia, hypoglycemia, dehydration, hypothermia <36.1°C, <80% healthy body weight, hepatic, renal or cardiac compromise, suicidal intent, poor motivation to recover, and coexisting psychiatric disorders. |
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. | Child behavior check list, Conners abbreviated rating scale, and Vanderbilt ADHD diagnostic rating scale. INCLEN diagnostic tool for ADHD is validated for Indian children. |
| b. | Thyroid disorders, hearing and vision deficits, neurodegenerative disorders, heavy metal poisoning, OCD, Fragile X syndrome, and response to psychosocial factors like abuse or inappropriate class setting. |
| c. | Multidisciplinary treatment including behavioral interventions, educational interventions, psychostimulant drugs such as methylphenidate, amphetamine, or atomoxetine, remedial education, and parents’ counseling. |
| d. | Family or personal history of cardiomyopathy, arrhythmia or syncope, and electrocardiogram/cardiology consultation, if required. |
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 or functional neurological symptom disorder. |
| b. | Children with a sensitive/insecure temperament, psychiatric comorbidities, preexisting illness, external environmental stressors in school and family, childhood trauma, and genetics. |
| c. | Multidisciplinary management including CBT, modifying parental response patterns, and pharmacological therapy for coexisting psychiatric conditions, if any. |
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. |
| b. | Older parental age, short interval between pregnancies, maternal obesity, and premature birth and prenatal infections with cytomegalovirus (CMV) or rubella. |
| c. | Chromosomal microarray and Fragile X, Rett syndrome, PTEN mutation disorders, (Down’s, Angelman, Smith–Lemli–Opitz, and Joubert syndrome). |
| d. | Intellectual disability, language impairments, ADHD, sleep disorders, gastroesophageal reflux disease, constipation, and epilepsy. |
| e. | Modified Checklist for Autism in Toddlers (M-CHAT), social communication questionnaire, Childhood Autism Rating Scale (CARS), and Trivandrum Autism Behavior Checklist. |
| f. | INCLEN tool, Indian scale for assessment of autism (ISAA), Autism Diagnostic Observation Scale (ADOS), and Autism Diagnostic Interview (ADI). |
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
f. Name some schemes available for the welfare of people with autism.
Answer
| a. | Language disorders, intellectual disability, global developmental delay, hearing loss, ADHD, social anxiety, and Landau–Kleffner syndrome. |
| b. | Head circumference, dysmorphic features, muscle tone and reflexes, and wood lamp examination for tuberous sclerosis. |
| c. | Micro- or macrocephaly, developmental regression, or focal findings on CNS examination. |
| d. | Applied behavioral analysis (ABA) methods such as joint attention, shared enjoyment, and reciprocal communication and educational approaches such as Treatment and Education of Autistic and Communication Handicapped Children (TEACCH), speech and language therapy, augmentative communication, social skills programs, and parent-mediated early intervention. |
| e. | (i) Risperidone, (ii) Methylphenidate, (iii) Fluoxetine, (iv) Melatonin. |
| f. | Niramaya (insurance), Aspiration (early intervention), and Gyan Prabha (scholarship). |
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. |
| b. | Stereotypies, compulsions, movement disorders like benign paroxysmal torticollis, Sandifer syndrome, and shuddering attacks. |
| c. | OCD, ADHD, learning disabilities, autism spectrum disorder, anxiety, and depression. |
| d. | Psychoeducation, behavioral interventions such as habit reversal therapy (HRT) and comprehensive behavioral intervention for tics (CBIT), and drugs such as haloperidol, aripiprazole, and clonidine. |
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. | Breath-holding spells. |
| b. | Seizures, cardiac arrhythmias, dysautonomia, and CNS lesions. |
| c. | Cyanotic spells, pallid spells, or mixed types. |
| d. | Advise parents to ignore the breath holding since it usually self resolves, for older children parents can calmly advise the child of expected behavior or give time out, if nothing works referral for mental health evaluation. |
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. | ODD can be classified as: |
| • | Mild—when symptoms occur in only one setting (at home/school/work/peers) |
| • | Moderate—when symptoms occur in at least 2 settings |
| • | Severe—when symptoms occur in >4 settings |
| c. | Conduct disorder, intermittent explosive disorder, ADHD, and bipolar disorder. |
| d. | Suicidal behavior, delinquency, criminal behavior, substance abuse, and academic, occupational, and marital failure. |
| e. | Guided self-help methods, cognitive behavioral therapy for the child, and help for parents such as parent training and positive parenting program. |
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. |
| b. | ADHD, autism spectrum disorder, communication disorders, and developmental coordination disorders. |
| c. | Malin’s Intelligence Scale for Indian Children, NIMHANS index, Binet Kamat Test, and Grade Level Assessment Device (GLAD). |
| d. | Remediation methods for critical and numeracy skills, accommodations such as changes in teaching and assessments, and modifications like lowering level of teaching. |
| e. | Specific learning disorder comes under Right of Persons with Disability Act 2016 for free education till 18 years and concessions are given for students in examinations. |