Somatic Symptoms Related Disorders Substance Use and Addictive Disorders Child Psychiatry Neurocognitive Disorders

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What's Covered

1. Somatic Symptom & Related Disorders

Full breakdown of all 6 disorders: SSD, Illness Anxiety, Conversion, Psychological Factors, Factitious, and Malingering
Differential diagnosis table distinguishing intentionality, organic cause, and gain type
16-point red flag table for Factitious Disorder
Treatment by disorder type

2. Substance Use & Addictive Disorders

DSM-5 unified criteria (11-item spectrum, severity levels)
Alcohol withdrawal timeline + pharmacotherapy (naltrexone, acamprosate, disulfiram)
Wernicke–Korsakoff syndrome
Opioid withdrawal vs. intoxication + treatment (methadone, buprenorphine, naltrexone)
Stimulant, cannabis, benzodiazepine, and nicotine use disorders
CRAFFT adolescent screening tool
Dual diagnosis considerations

3. Child Psychiatry

DSM-5-TR classification updates (ASD, DMDD, Specific Learning Disorder)
ADHD — criteria, presentations, neurobiology, treatment
ASD — core domains, epidemiology, neuroimaging, therapy
Anxiety, MDD, ODD, Conduct Disorder, Tourette syndrome
Developmental milestones table
Treatment modalities including post-COVID telehealth

4. Neurocognitive Disorders

DSM-5 Major vs. Mild NCD framework
Delirium (types, causes, management)
Alzheimer's (genetics, neuropathology, neurotransmitters, staging, treatments including lecanemab)
Vascular, Lewy Body, Frontotemporal, Parkinson's, HIV dementias
Depression vs. Dementia differentiation table
Reversible causes (DEMENTIA mnemonic)
Summary comparison table of all NCD types

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I now have rich textbook content from Kaplan & Sadock's Comprehensive Textbook, Synopsis of Psychiatry, and Maudsley Prescribing Guidelines. Here are your full long-answer resources for Child Psychiatry in all three formats:

📝 CHILD PSYCHIATRY — LONG ANSWER QUESTIONS

FORMAT 1: EXAM-STYLE ESSAYS (Structured Headings)

Essay Question 1

"Discuss Attention-Deficit/Hyperactivity Disorder (ADHD) in children — its aetiology, clinical features, diagnosis, and management."

Introduction

Attention-Deficit/Hyperactivity Disorder (ADHD) is one of the most common neurodevelopmental disorders of childhood, affecting 6–9% of children and adolescents worldwide. It is characterised by persistent, developmentally inappropriate patterns of inattention, hyperactivity, and impulsivity that cause significant functional impairment across multiple settings. The disorder persists into adulthood in approximately 50% of patients.

Aetiology and Neurobiology

ADHD arises from a complex interaction of genetic, neurobiological, and environmental factors.

Genetic factors:

Heritability estimated at ~75–80%; first-degree relatives of affected children have a 2–8× increased risk
Genome-wide association studies implicate genes involved in dopamine regulation: DRD4, DRD5, DAT1 (dopamine transporter gene), SNAP-25
Genetic overlap with autism spectrum disorder, schizophrenia, and conduct disorder

Neurobiological factors:

Core dysfunction in prefrontal cortical circuits regulating executive function
Deficient dopaminergic and noradrenergic neurotransmission in fronto-striatal and fronto-cerebellar networks
Neuroimaging: delayed cortical maturation (peak cortical thickness reached ~3 years later); reduced volume of caudate nucleus, prefrontal cortex, and cerebellum
Synaptic pruning and myelination continue through adolescence — explaining persistence of symptoms

Environmental/Perinatal risk factors:

Prenatal exposure to tobacco, alcohol, lead
Prematurity and low birth weight
Psychosocial adversity; severe institutional neglect (overlap with DSED)
Diet (minimal role; food additives controversy not strongly supported)

Clinical Features

DSM-5-TR requires ≥6 symptoms (or ≥5 if aged ≥17 years) in either inattentive or hyperactive-impulsive domain, persisting for ≥6 months, present in ≥2 settings, with onset of symptoms before age 12, causing significant functional impairment.

Three presentations:

1. Predominantly Inattentive (ADHD-I)

Fails to give close attention to details; makes careless errors
Difficulty sustaining attention in tasks or play
Does not seem to listen when spoken to directly
Fails to follow through on instructions; loses things
Easily distracted by extraneous stimuli
Forgetful in daily activities
Avoids tasks requiring sustained mental effort

2. Predominantly Hyperactive-Impulsive (ADHD-HI)

Fidgets with hands/feet, squirms in seat
Leaves seat in situations where remaining seated is expected
Runs about or climbs in inappropriate situations
Unable to play quietly
Talks excessively; blurts out answers before question is complete
Difficulty waiting turn; interrupts or intrudes on others

3. Combined Presentation (ADHD-C)

Most common clinical presentation
Meets criteria for both inattentive and hyperactive-impulsive

Associated features:

Low frustration tolerance, emotional dysregulation
Academic underachievement
Impaired social relationships
Low self-esteem
Increased risk of accidental injury
Comorbidities: ODD (50%), anxiety disorders (30–40%), MDD (20–30%), specific learning disorder, tics, ASD

Diagnosis

ADHD is a clinical diagnosis — there is no confirmatory blood test or imaging finding.

Assessment should include:

Detailed developmental and psychiatric history (parent and child)
Standardised rating scales:
- Conners' Rating Scales (parent, teacher, and self-report)
- Vanderbilt ADHD Diagnostic Rating Scale
- SNAP-IV
Direct observation of the child
School/teacher report to confirm cross-setting impairment
Neuropsychological testing (optional; for learning disability assessment)
Rule out:
- Hearing/vision problems
- Thyroid dysfunction
- Epilepsy (especially absence seizures mimicking inattention)
- Anxiety and mood disorders
- Sleep disorders (OSAS causing inattention)
- Lead toxicity

Differential diagnosis:

Condition	Key Distinguishing Feature
Normal developmental variation	Symptoms not impairing; context-specific
Anxiety disorder	Inattention secondary to worry; no hyperactivity
ASD	Social deficits, restricted interests; ADHD can be comorbid
DSED	Disinhibition without inattention/hyperactivity
Absence epilepsy	Brief spells; EEG confirms
Conduct disorder	Deliberate defiance; may be comorbid
Bipolar disorder	Episodic course; grandiosity; sleep changes

Management

Management should be multimodal, combining pharmacological and psychosocial approaches, always individualised to the child's age, severity, and comorbidities.

A. Psychosocial / Behavioural Interventions

Intervention	Target Group	Content
Behavioural Parent Training	Children <12	Parents learn positive reinforcement, consistent limits, reward charts
Classroom accommodations	School-age	Preferential seating, extended time, reduced distraction
CBT	Older children/adolescents	Organisation, time management, emotional regulation
Social skills training	Children with social impairment	Turn-taking, conflict resolution

For children aged <6 years, parent training is first-line; medication is second-line only if psychosocial interventions are insufficient.

B. Pharmacological Treatment

Stimulants — First Line

Stimulants (dopamine/norepinephrine reuptake inhibitors) are the best-evidenced pharmacotherapy. 65–75% of stimulant-treated youth respond. Response rates are comparable between methylphenidate and amphetamine classes, but individual response may differ.

Agent	Class	Formulation	Notes
Methylphenidate (MPH)	Stimulant	IR (BID/TID) or ER (once daily)	First-line; robust RCT/meta-analysis evidence
Dexamfetamine	Stimulant	IR or ER	Alternative; somewhat less evidence than MPH; higher diversion risk
Lisdexamfetamine (LDX)	Pro-drug stimulant	ER capsule (once daily)	Converted to active dexamfetamine in RBCs; lower abuse potential; network meta-analyses show superiority over MPH
Mixed amphetamine salts (Adderall)	Stimulant	IR/XR	Widely used in the USA

Key adverse effects of stimulants: Insomnia, appetite suppression, weight loss, elevated BP/HR, growth deceleration with long-term use (monitor height/weight 6-monthly). Managed by treatment breaks, dose adjustment, or timing changes.

Non-Stimulants — Second Line

Agent	Mechanism	Notes
Atomoxetine	SNRI (selective norepinephrine reuptake inhibitor)	Useful when stimulant diversion is a concern, or when tics/anxiety worsen on stimulants; warn parents of suicidal ideation risk (black box) and liver disease
Guanfacine ER	α2A agonist	Licensed in UK and USA; broadly as effective as atomoxetine; can be combined with stimulants
Clonidine ER	α2 agonist	Useful especially for hyperactivity/impulsivity and sleep difficulties; sedating
Viloxazine	Norepinephrine reuptake inhibitor	FDA approved; effective; newer agent
Bupropion	NRI/NDRI	Some evidence; not first- or second-line

Dosing principles:

Adequate methylphenidate trial: >0.8 mg/kg/day
Adequate amphetamine trial: >0.5 mg/kg/day
Extended-release (ER) formulations preferred — improve adherence, reduce abuse potential
An afternoon "booster" of IR stimulant may be needed with some ER preparations

C. Monitoring

Height, weight, and BMI at every visit
Blood pressure and heart rate
Sleep and appetite review
Rating scales at follow-up to assess symptom control
Review stimulant-free periods ("drug holidays") annually

Prognosis

Symptoms improve with age in ~50% (hyperactivity more than inattention)
~50% of children with ADHD continue to meet criteria in adulthood
Good prognosis associated with: higher IQ, strong family support, early intervention, no comorbid conduct disorder
Untreated ADHD: increased risk of academic failure, substance use disorder, antisocial behaviour, driving accidents

Essay Question 2

"Write an essay on Autism Spectrum Disorder (ASD) in children — classification, aetiology, clinical features, diagnosis, and management."

Introduction

Autism Spectrum Disorder (ASD) is a neurodevelopmental disorder characterised by persistent deficits in social communication/interaction and restricted, repetitive patterns of behaviour, interests, or activities. Introduced as a unified diagnosis in DSM-5 (2013), ASD subsumed the previously separate diagnoses of Autistic Disorder, Asperger Disorder, Childhood Disintegrative Disorder, Rett Disorder, and PDD-NOS. Its prevalence is approximately 1 in 36 children (CDC 2023), with a male-to-female ratio of approximately 4:1.

Classification and Severity Levels

DSM-5-TR specifies three severity levels based on the degree of support required:

Level	Social Communication	Restricted/Repetitive Behaviours
Level 1 (Requiring support)	Noticeable impairments; difficulties initiating interaction	Inflexibility causes significant interference
Level 2 (Requiring substantial support)	Marked deficits; limited initiation; abnormal responses	Repetitive behaviours frequently apparent
Level 3 (Requiring very substantial support)	Severe deficits; minimal functional verbal communication	Extreme difficulty with change; severe impact

Specifiers: With/without intellectual impairment; with/without language impairment; associated with a known medical/genetic condition.

Aetiology

Genetic factors (strongest influence):

Heritability ~80–90% (concordance in MZ twins ~60–90%)
Chromosomal abnormalities: 22q11.2 deletion, 15q11-q13 duplication, fragile X
De novo copy number variants (CNVs) and point mutations: SHANK3, NRXN1, CNTNAP2, CHD8
Genome-wide association studies (GWAS) identify overlapping loci with schizophrenia and ADHD

Neurobiological factors:

Accelerated brain growth in the first 1–2 years of life followed by abnormal pruning
Abnormal amygdala habituation — poor adaptation to repeated social stimuli
Disrupted long-range cortical connectivity (excess local, reduced long-range)
Cerebellar abnormalities; dysregulation of excitatory/inhibitory balance (↑ glutamate, ↓ GABA)
Oxytocin system dysfunction — role in social bonding

Environmental risk factors:

Advanced parental age
Prenatal valproate exposure (3–9× risk)
Very preterm birth
Prenatal infection (particularly influenza, cytomegalovirus)
Vaccines do NOT cause ASD — this has been definitively refuted

Core Clinical Features

Domain 1: Social Communication and Interaction (all three required)

Deficits in social-emotional reciprocity: reduced social approach, failure to share interests/emotions, failure to initiate/respond to interactions
Deficits in nonverbal communicative behaviours: poorly integrated verbal/nonverbal communication, limited eye contact, limited use of gestures, absent facial expressions
Deficits in developing, maintaining, and understanding relationships: difficulties adjusting behaviour to social context, absence of interest in peers, lack of imaginative/cooperative play

Domain 2: Restricted, Repetitive Behaviours, Interests, or Activities (≥2 of 4 required)

Stereotyped/repetitive motor movements, use of objects, or speech: simple motor stereotypies, lining up objects, echolalia, idiosyncratic phrases
Insistence on sameness, inflexible adherence to routines: extreme distress at small changes, rigid thinking, ritualistic greeting patterns
Highly restricted, fixated interests: intense preoccupation with unusual topics (trains, astronomy, dinosaurs); abnormal intensity/focus
Hyper- or hypo-reactivity to sensory input: apparent indifference to pain/heat, adverse responses to specific sounds/textures, excessive smelling/touching of objects, visual fascination with lights

Other associated features:

Intellectual disability (co-occurring in ~30–40%)
Language delay (range from nonverbal to hyperlexic)
Epilepsy (~25–30%)
Sleep disturbances (~50–80%)
ADHD (~50%), anxiety disorders (~40%), OCD-like behaviours
GI problems (constipation, feeding difficulties)
Mood dysregulation, self-injurious behaviour

Diagnostic Approach

Screening

M-CHAT-R/F (Modified Checklist for Autism in Toddlers, Revised with Follow-up): routine screening at 18 and 24 months
Red flags warranting immediate evaluation:
- No babbling by 12 months
- No single words by 16 months
- No 2-word spontaneous phrases by 24 months
- Any loss of language or social skills at any age

Diagnostic Tools

Tool	Age	Use
ADOS-2 (Autism Diagnostic Observation Schedule-2)	All ages	Gold-standard structured observation
ADI-R (Autism Diagnostic Interview-Revised)	All ages	Structured parent interview
CARS (Childhood Autism Rating Scale)	All ages	Severity rating

Investigations

Chromosomal microarray (CMA) — first-line genetic test
Fragile X testing
Metabolic screen (if intellectual disability)
EEG if seizures suspected
Hearing assessment (rule out hearing impairment)
MRI — not routine; only if focal neurological signs or regression

Differential diagnosis:

Language disorder — social interaction intact
Social (Pragmatic) Communication Disorder — social communication deficits WITHOUT restricted/repetitive behaviours
ADHD — can be comorbid; hyperactivity/impulsivity without restricted interests
Intellectual disability — social development proportional to cognitive level
Reactive Attachment Disorder (RAD) — history of social neglect; language not deviant/stereotyped; no RRBs

Management

There is no cure for ASD. The goal is to maximise function, communication, and quality of life. Early intensive intervention (before age 3) produces the best long-term outcomes.

A. Behavioural Therapies

Therapy	Description
ABA (Applied Behaviour Analysis)	Systematic reinforcement of adaptive behaviours; reduces maladaptive behaviours; most evidence-based; ideally 25–40 hrs/week
EIBI (Early Intensive Behavioural Intervention)	ABA-based for toddlers/preschoolers
PECS (Picture Exchange Communication System)	Augmentative communication for non-verbal children
Social skills groups	Structured peer interaction, perspective-taking
DIR/Floortime	Relationship-based, child-led developmental model

B. Educational Approaches

Specialised educational placement (small class sizes, structured environment)
Sensory integration therapy (occupational therapy)
Individualised Education Plan (IEP)
Augmentative and Alternative Communication (AAC) devices for non-verbal children

C. Pharmacological Treatment

No medication treats the core features of ASD. Medications target associated symptoms.

Medication	Indication	FDA Status
Risperidone	Irritability, self-injurious behaviour, aggression	FDA approved (≥5 years)
Aripiprazole	Irritability, aggression	FDA approved (≥6 years)
Melatonin	Sleep disturbance	Evidence-based
SSRIs	Anxiety, repetitive behaviours (limited evidence in children)	Off-label
Methylphenidate/Atomoxetine	Comorbid ADHD	Off-label (less robust response than non-ASD ADHD)
Valproate	Epilepsy; some evidence for aggression	Off-label

D. Family Support

Parent training in ABA techniques
Sibling support groups
Respite care
Educational advocacy
Transition planning to adult services

Prognosis

Highly variable; best outcomes correlate with: higher IQ, functional language by age 5, early diagnosis and intervention
~10% achieve independent adult functioning
Adults often require supported living, sheltered employment
Life expectancy near-normal unless severe medical comorbidities

Essay Question 3

"Discuss Conduct Disorder and Oppositional Defiant Disorder in children and adolescents — clinical features, aetiology, and management."

Introduction

Oppositional Defiant Disorder (ODD) and Conduct Disorder (CD) are the two most common disruptive behaviour disorders of childhood. They exist on a continuum of severity, with ODD representing the milder end and CD representing a more serious pattern involving violation of others' fundamental rights and social norms. Both are associated with significant impairment in academic, social, and family functioning.

Oppositional Defiant Disorder (ODD)

DSM-5-TR Criteria: A pattern of angry/irritable mood, argumentative/defiant behaviour, and/or vindictiveness lasting ≥6 months, with ≥4 symptoms from the following categories:

Angry/Irritable Mood:

Often loses temper
Often touchy or easily annoyed
Often angry and resentful

Argumentative/Defiant Behaviour:

Often argues with authority figures
Often actively defies or refuses to comply with rules
Often deliberately annoys others
Often blames others for own mistakes

Vindictiveness:

Has been spiteful or vindictive ≥twice in past 6 months

Severity: Mild (one setting), Moderate (two settings), Severe (three or more settings)

Key distinction from CD: ODD does NOT include serious violations of others' rights, physical aggression, or destruction of property.

Conduct Disorder (CD)

DSM-5-TR Criteria: A repetitive and persistent pattern of behaviour violating the basic rights of others or major age-appropriate social norms, with ≥3 of 15 criteria in the past 12 months (≥1 in past 6 months):

Aggression to People and Animals:

Bullies, threatens, or intimidates others
Often initiates physical fights
Used a weapon that could cause serious physical harm
Physically cruel to people or animals
Has stolen while confronting a victim (mugging, robbery)
Forced sexual activity on someone

Destruction of Property:

Deliberately set fires to cause serious damage
Deliberately destroyed property

Deceitfulness or Theft:

Broken into a house, building, or car
Often lies to obtain goods or avoid obligations ("cons" others)
Stolen items without confronting a victim (shoplifting, forgery)

Serious Violations of Rules:

Stays out at night despite parental prohibition (before age 13)
Ran away from home overnight ≥twice (or once for a lengthy period)
Often truant from school (before age 13)

Subtypes:

Childhood-onset (<10 years): more likely male; more persistent; associated with antisocial personality disorder in adulthood
Adolescent-onset (≥10 years): better prognosis; more likely to remit; peers play greater role

With Limited Prosocial Emotions (callous-unemotional traits) specifier: Lack of remorse/guilt, callous lack of empathy, unconcerned about performance, shallow/deficient affect — associated with more severe, persistent, and treatment-resistant course.

Aetiology (shared for ODD and CD)

Biological factors:

Genetic heritability ~40–70%
Lower resting heart rate (marker of fearlessness/sensation-seeking)
Reduced cortisol reactivity (HPA axis hyporesponsiveness)
Structural brain differences: reduced grey matter in prefrontal cortex, amygdala, insula
Lower serotonin activity

Psychological/Temperament factors:

Difficult temperament (high negative emotionality, low self-regulation)
Poor executive function (impulse control, planning)
Hostile attributional bias — tendency to interpret ambiguous situations as threatening
Callous-unemotional traits (reduced empathy, guilt)
Low academic achievement

Family and Environmental factors (Patterson Coercive Cycle):

Inconsistent, harsh, or neglectful parenting
Negative coercive cycles: child is demanding → parent becomes controlling → child seeks attention through misbehaviour → parent's control escalates → child fails to internalise self-regulation
Parental psychopathology (depression, antisocial behaviour, substance abuse)
Domestic violence, poverty, overcrowding
Exposure to violence in community
Deviant peer group (particularly for adolescent-onset CD)
Media violence (cumulative exposure associated with increased aggression)

Risk factors specific to conduct disorder severity:

Urban residence / community violence
Gang involvement
Incarcerated parent
Early substance use

Management

A. Psychosocial Interventions (First-Line)

Intervention	Target	Description
Parent-Child Interaction Therapy (PCIT)	Preschool/young children (ages 2–6) with ODD	Two-phase: CDI (Child-Directed Interaction — builds warmth) then PDI (Parent-Directed Interaction — consistent limits); >30 clinical trials confirm efficacy
Parent Management Training (PMT)	School-age children	Parents learn techniques for setting limits, applying consequences, withstanding defiant behaviour; builds parental self-control and united adult front
Multisystemic Therapy (MST)	Adolescents with delinquency/juvenile justice involvement	Intensive (3–4 contacts/week for 4 months); therapist addresses family, peer, school, and community systems; reduces recidivism
CBT for child	School-age and adolescents	Problem-solving skills training; anger management; perspective-taking; social information processing
Fast Track Programme	High-risk children from childhood	Long-term multi-component prevention; reduces CD rates over childhood

Family therapy goals:

Establish warm, respectful parent-child relationship
Break coercive interaction cycles
Improve parental supervision and limit-setting
Address parental stressors (mental illness, poverty, domestic violence)

B. School-Based Interventions

Classroom behaviour management strategies
Social skills groups
Teacher consultation

C. Pharmacological Treatment

No FDA-approved medication specifically for ODD or CD.

Medication	Indication	Evidence
Risperidone	Severe aggression; below-average IQ	RCT evidence; FDA approved for irritability in ASD — used off-label for CD
Aripiprazole	Aggression	Some evidence
Mood stabilisers (lithium, valproate)	Explosive aggression; CD with mood instability	Sodium valproate shows symptomatic response in CD subtypes
Stimulants	When comorbid ADHD is present	Treating ADHD often reduces associated oppositional/conduct symptoms
SSRIs	Comorbid anxiety/depression	Indirect benefit
Clonidine	Impulsivity, hyperactivity, aggression	Off-label

Prognosis

Predictor	Good Prognosis	Poor Prognosis
Onset	Adolescent-onset	Childhood-onset
Severity	Mild	Severe; many symptoms
Callous-unemotional traits	Absent	Present
IQ	Higher	Lower
Family	Stable, supportive	Dysfunctional
Comorbidities	Absent/treated	Multiple untreated

~40% of childhood-onset CD → Antisocial Personality Disorder (ASPD) in adulthood
ODD: ~25% progress to CD; remainder remit or develop anxiety/mood disorders
ODD → CD pathway is not inevitable; early intervention is effective

FORMAT 2: CLINICAL CASE-BASED DISCUSSION

Case 1 — ADHD

Case: 8-year-old Amir is brought by his mother because his teacher reports he "cannot sit still, never completes tasks, and constantly disrupts the class." His mother says he has always been "on the go," loses his school bag daily, and gets distracted by the slightest noise. He was excluded from two activities at school. His grades are dropping. Physical examination and hearing test are normal.

Discussion Questions & Model Answers:

Q1. What is the most likely diagnosis and what additional information would you seek?

Most likely diagnosis: ADHD, combined presentation. I would confirm symptoms across settings (home + school, hence ≥2 settings), establish that onset was before age 12, quantify functional impairment, and use standardised rating scales (Conners', SNAP-IV) completed by both parent and teacher. I would rule out absence epilepsy (brief attentional lapses), anxiety disorder, and hearing impairment (already excluded here).

Q2. How would you manage this child?

First-line: Behavioural parent training + classroom accommodations (preferential seating, extended test time, task chunking). If adequate psychosocial intervention fails: methylphenidate ER (first-line stimulant) at an adequate dose (target >0.8 mg/kg/day). Monitor height, weight, BP, HR, and sleep at each visit. Review annually for medication breaks.

Q3. The child develops tics after starting methylphenidate. What do you do?

Dose reduction first. If tics persist, consider switching to a non-stimulant: guanfacine ER (also addresses hyperactivity/tics) or atomoxetine. Tics are a recognised side effect of stimulants, particularly in children with a family history of tic disorders.

Case 2 — ASD

Case: Sana is a 2.5-year-old girl referred by her paediatrician. Her parents noticed she doesn't wave bye-bye, doesn't point at things to show interest, and rarely makes eye contact. She has 5 words but uses them inconsistently. She lines up her toy cars for hours and is very distressed when her routine is disrupted. She does not play alongside other children.

Discussion Questions & Model Answers:

Q1. What are the red flags for ASD present in this case?

No consistent pointing (deficit in joint attention — an early core ASD marker)
No waving (absent communicative gesture)
Poor eye contact (nonverbal communication deficit)
Language regression/inconsistency
Restricted repetitive behaviour (lining up cars)
Insistence on sameness (routine disruption causes distress)
Absent parallel/cooperative play

Q2. What investigations and diagnostic tools would you use?

ADOS-2 (gold-standard structured observation) + ADI-R (structured parent interview)
M-CHAT-R/F already positive → formal evaluation
Audiological assessment (rule out hearing impairment)
Chromosomal microarray (first-line genetic test)
Fragile X testing
Metabolic screen (given young age and regression)
No routine MRI unless focal neurological signs

Q3. What treatment would you initiate?

Early Intensive Behavioural Intervention (EIBI/ABA) — ideally 25–40 hrs/week
Speech and language therapy (core deficit)
Occupational therapy (sensory integration, fine motor)
PECS if limited verbal communication
Parent training in naturalistic ABA strategies (PRT — Pivotal Response Training)
Educational placement in specialised early intervention setting
No pharmacotherapy at this stage unless severe comorbid symptoms emerge
Referral to developmental paediatrician and child psychiatrist
Family support and parent psychoeducation

Case 3 — Conduct Disorder

Case: 14-year-old Rayan is brought to the outpatient clinic by his mother after school suspension for fighting and threatening a teacher. History reveals he has been stealing from family members, stays out overnight without permission, has been shoplifting since age 12, and was recently arrested for vandalism. He shows no remorse. His father is in prison. His mother describes him as "always been a difficult child." He started skipping school at age 11.

Discussion Questions & Model Answers:

Q1. Identify DSM-5-TR criteria met for Conduct Disorder.

Physical fights (aggression to people)
Threatening behaviour toward teacher (intimidation)
Stealing from family (theft without confrontation)
Shoplifting (theft without confrontation) — onset <13
Vandalism (destruction of property)
Staying out overnight without permission
Truancy beginning before age 13
No remorse → Limited Prosocial Emotions (callous-unemotional) specifier applies

This is childhood-onset CD (onset <10 years implied by early stealing/truancy) with callous-unemotional traits — most severe subtype with poorest prognosis.

Q2. What risk factors are evident?

Biological: callous-unemotional traits; possible genetic loading. Family: incarcerated father; inconsistent/overwhelmed parenting; likely coercive interaction cycles. Environmental: poverty implied; community exposure to delinquency. Psychological: hostile attributional bias, poor impulse control.

Q3. Outline your management plan.

Risk assessment — safety of Rayan and others; safeguarding issues
Multisystemic Therapy (MST) — given adolescent age, delinquency, and juvenile justice involvement; 4-month intensive programme addressing all systems
Parental support — mother needs coaching in limit-setting; family therapy to break coercive cycle
School liaison — reintegration plan, educational support
Treat comorbidities — screen for ADHD, depression, substance use (CRAFFT screening)
Pharmacotherapy (if aggression is severe and unresponsive to psychosocial measures): risperidone off-label; mood stabiliser (valproate) if explosive aggression
If juvenile justice involved: coordinate with youth offending team

FORMAT 3: OSCE / VIVA-STYLE Q&A

Topic: ADHD

Q: What are the three presentations of ADHD in DSM-5? A: Predominantly inattentive, predominantly hyperactive-impulsive, and combined presentation.

Q: At what age must symptoms have been present to diagnose ADHD in DSM-5? A: Before age 12.

Q: In how many settings must symptoms cause impairment? A: At least two (e.g., home AND school).

Q: What is the first-line pharmacological treatment for ADHD? A: Methylphenidate (stimulant). Lisdexamfetamine is an alternative — network meta-analyses suggest it may be more effective.

Q: Name two non-stimulant options for ADHD. A: Atomoxetine (SNRI) and guanfacine ER (α2A agonist).

Q: What are the side effects of methylphenidate? A: Insomnia, appetite suppression, growth deceleration, elevated BP and HR. Long-term use associated with lower height and weight.

Q: In what situation would you prefer atomoxetine over methylphenidate? A: When stimulant diversion is a concern; when dopaminergic side effects (tics, anxiety, stereotypies) are problematic; when stimulants have failed.

Q: What percentage of children with ADHD persist into adulthood? A: Approximately 50%.

Q: Name a condition that can mimic inattentive ADHD. A: Absence epilepsy, anxiety disorder, hearing impairment, sleep disorder (OSAS).

Q: What neurobiological system is primarily implicated in ADHD? A: Dopaminergic and noradrenergic dysfunction in fronto-striatal circuits; delayed cortical maturation of the prefrontal cortex.

Topic: ASD

Q: Name the two core diagnostic domains of ASD in DSM-5. A: (1) Persistent deficits in social communication and interaction; (2) Restricted, repetitive patterns of behaviour, interests, or activities.

Q: What five diagnoses did ASD subsume from DSM-IV? A: Autistic disorder, Asperger disorder, childhood disintegrative disorder, Rett disorder, PDD-NOS.

Q: What is joint attention and why is it clinically significant in ASD? A: Joint attention is the shared focus of two individuals on an object, achieved through pointing, showing, and gaze-following. Its absence in the second year of life is one of the earliest and most sensitive red flags for ASD.

Q: What is the gold-standard observational tool for diagnosing ASD? A: ADOS-2 (Autism Diagnostic Observation Schedule, 2nd edition).

Q: At what developmental age is the M-CHAT used? A: 16–30 months (routine screening at 18 and 24 months).

Q: What is the most important genetic test to request in ASD? A: Chromosomal microarray (CMA).

Q: What are the FDA-approved medications for ASD? A: Risperidone (≥5 years) and aripiprazole (≥6 years) — both for irritability (not core ASD symptoms).

Q: What is the difference between ASD and Social (Pragmatic) Communication Disorder? A: Both have social communication deficits. ASD additionally has restricted, repetitive behaviours/interests — which are ABSENT in Social Communication Disorder.

Q: Name a prenatal medication associated with increased ASD risk. A: Valproate (3–9-fold increased risk).

Q: What does the research say about vaccines and ASD? A: No causal association — the original Wakefield study was retracted and his medical licence revoked. Multiple large epidemiological studies have definitively refuted the link.

Topic: Conduct Disorder / ODD

Q: What is the key distinction between ODD and Conduct Disorder? A: ODD involves angry/irritable mood, argumentative/defiant behaviour, and vindictiveness — but does NOT involve serious violations of others' rights or physical aggression, theft, or property destruction, which characterise CD.

Q: What specifier in DSM-5 indicates the most severe, treatment-resistant form of CD? A: "With Limited Prosocial Emotions" (callous-unemotional traits): lack of remorse/guilt, callous lack of empathy, unconcerned about performance, shallow affect.

Q: Childhood-onset CD is defined as onset before what age? A: Before age 10.

Q: Which has a worse prognosis — childhood-onset or adolescent-onset CD? A: Childhood-onset — more persistent, more likely to progress to antisocial personality disorder in adulthood.

Q: What percentage of childhood-onset CD progresses to ASPD? A: Approximately 40%.

Q: What is the first-line psychosocial treatment for preschool ODD? A: Parent-Child Interaction Therapy (PCIT) — evidence from >30 clinical trials.

Q: What is Multisystemic Therapy (MST)? A: An intensive, home-based intervention for adolescents with delinquency; involves 3–4 contacts per week for 4 months; addresses family, school, peer, and community systems; shown to reduce recidivism.

Q: Describe the Patterson Coercive Cycle. A: Child's demanding behaviour → parent becomes controlling → child misbehaves to get attention → parent escalates control → child fails to learn self-regulation → parent becomes disempowered and hopeless. This negative cycle perpetuates ODD/CD.

Q: Is there any FDA-approved medication for conduct disorder? A: No. Risperidone (FDA-approved for ASD irritability) is used off-label for severe aggression. Treating comorbid ADHD with stimulants often reduces associated disruptive behaviours.

Q: What environmental factors increase risk for conduct disorder? A: Parental psychopathology/substance abuse, domestic violence, poverty, overcrowding, community violence, deviant peer group, incarcerated parent, inconsistent/harsh parenting.

Sources: Kaplan & Sadock's Comprehensive Textbook of Psychiatry; Kaplan and Sadock's Synopsis of Psychiatry; The Maudsley Prescribing Guidelines in Psychiatry, 15th Ed.

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