Chapter 30: Neurodevelopmental, Behavioral and Mental Health Disorders

Garzon Maaks: Burns’ Pediatric Primary Care, 7th Edition

MULTIPLE CHOICE

1. A child diagnosed with attention-deficit/hyperactivity disorder (ADHD) has difficulty

stopping activities to begin other activities at school. The primary care pediatric nurse
practitioner understands that this is due to difficulty with what self-regulation ability?
a. Emotional control
b. Flexibility
c. Inhibition
d. Problem-solving
ANS: B
Flexibility is a component of self-regulation, which is under the control of executive functions
in the cerebral cortex and is the ability to shift or transition between activities or thoughts.
Emotional control is the ability to modify emotional expression to the most adaptive
expression. Inhibition refers to the ability to stop or delay an initial response. Problem solving
is a component of metacognition.

2. The primary care pediatric nurse practitioner cares for a preschool-age child who was exposed
to drugs prenatally. The child bites other children and has tantrums when asked to stop but is
able to state later why this behavior is wrong. This child most likely has a disorder related to
what process?
a. Executive function
b. Information processing
c. Sensory processing
d. Social cognition
ANS: A
Children with prenatal drug or alcohol exposure often have executive function disorders,
characterized by an inability to stop or delay a response or interrupt an inappropriate behavior
and an inability to modify emotional expression appropriately. Information processing refers
to thinking and problem-solving ability. Sensory processing has to do with the ability to take
in information through senses and to process it appropriately. Social cognition refers to the
ability to interpret behavior and emotions of the self and others.

3. The parent of a child diagnosed with attention-deficit/hyperactivity disorder (ADHD) tells the
primary care pediatric nurse practitioner that the child gets overwhelmed by homework
assignments, doesn’t seem to know which ones to do first, and then doesn’t do any
assignments. The nurse practitioner tells the parent that this represents impairment in which
executive function?
a. Activation
b. Effort
c. Emotion
d. Focus
ANS: A
 Activation is an executive function that helps individuals organize, prioritize, and begin
activities. This child cannot prioritize a group of assignments and winds up not doing any of
them, showing an inability to prioritize and begin activities. Effort is the function associated
with sustaining effort and regulating awareness. Emotion is the function of managing
frustration. Focus is associated with sustaining and shifting attention to a task.

4. The primary care pediatric nurse practitioner is performing an examination on a 5-year-old

child who exhibits ritualistic behaviors, avoids contact with other children, and has limited
speech. The parent reports having had concerns more than 2 years ago about autism, but was
told that it was too early to diagnose. What will the nurse practitioner do first?
a. Administer an M-CHAT screen to screen the child for communication and
socialization delays.
b. Ask the parent to describe the child’s earlier behaviors from infancy through
preschool.
c. Reassure the parent that if symptoms weren’t present earlier, the likelihood of
autism is low.
d. Refer the child to a pediatric behavioral specialist to develop a plan of treatment
and management.
ANS: B
The DSM-5 criteria state that a patient must show symptoms from early childhood even if the
symptoms are not recognized until later in life. The parent had noticed symptoms prior but
was told not to worry; these symptoms should be evaluated in light of the current symptoms.
The M-CHAT is used for infants and toddlers and not for school-age children. Autism
symptoms are generally evident by age 3 years. The PNP should complete the assessment
before making a referral.

5. The primary care pediatric nurse practitioner is examining a 3-year-old child who speaks
loudly, in a monotone, does not make eye contact, and prefers to sit on the exam room floor
moving a toy truck back and forth in a repetitive manner. Which disorder does the nurse
practitioner suspect?
a. Attention-deficit/hyperactivity disorder
b. Autism spectrum disorder
c. Executive function disorder
d. Sensory processing disorder
ANS: B
Autism spectrum disorder manifests in toddlers by alterations in socialization and speech as
described above, along with repetitive behaviors. ADHD manifests with a lack of focus on
activities and distractibility. Executive function disorders can manifest in a variety of ways but
not with repetitive behaviors. Children with sensory processing disorders have altered
responses to sensations.

6. The primary care pediatric nurse practitioner is performing an examination on a 5-year-old

child who exhibits ritualistic behaviors, avoids contact with other children, and has limited
speech. The parent reports having had concerns more than 2 years ago about autism, but was
told that it was too early to diagnose. What will the nurse practitioner do first?
a. Administer an M-CHAT screen to screen the child for communication and
socialization delays.
b. Ask the parent to describe the child’s earlier behaviors from infancy through
 preschool.
c. Reassure the parent that if symptoms weren’t present earlier, the likelihood of
autism is low.
d. Refer the child to a pediatric behavioral specialist to develop a plan of treatment
and management.
ANS: B
The DSM-5 criteria state that a patient must show symptoms from early childhood even if the
symptoms are not recognized until later in life. The parent had noticed symptoms prior but
was told not to worry; these symptoms should be evaluated in light of the current symptoms.
The M-CHAT is used for infants and toddlers and not for school-age children. Autism
symptoms are generally evident by age 3 years. The PNP should complete the assessment
before making a referral.

7. The primary care pediatric nurse practitioner is conducting a follow-up examination on a child
who has recently begun taking a low-dose stimulant medication to treat
attention-deficit/hyperactivity disorder (ADHD). The child’s school performance and home
behaviors have improved. The child’s parent reports noticing a few tics, such a twitching of
the eyelids, but the child is unaware of them and isn’t bothered by them. What will the nurse
practitioner recommend?
a. Adding an alpha-agonist medication
b. Changing to a non-stimulant medication
c. Continuing the medication as prescribed
d. Stopping the medication immediately
ANS: C
Tics may occur as a side effect of stimulant medications but do not need to be discontinued if
there is a net benefit and the symptoms are not disturbing to the child. It is not necessary to
add an alpha-agonist, change to a non-stimulant medication, or stop the medication.

8. A 9-year-old child exhibits school refusal and a reluctance to attend sleepovers with
classmates. The parent is concerned because the child has recently begun sleeping in the
parents’ bed. Which initial action by the primary care pediatric nurse practitioner is
appropriate?
a. Assess for environmental stress, parental dysfunction, and maternal depression.
b. Ask about recent traumatic events that may have precipitated this behavior.
c. Consider a possible pediatric autoimmune neuropsychiatric disorder cause.
d. Recommend firm insistence on school and activity attendance.
ANS: A
This child shows symptoms of separation anxiety disorder. Environmental stress, parental
dysfunction, and maternal depression are risk factors for this disorder. Assessing for traumatic
events is necessary if PTSD is suspected. Pediatric autoimmune neuropsychiatric disorder
manifests with OCD- and Tourette-like symptoms. If the child does have separation anxiety
disorder (SAD), treatment and not discipline is warranted.

9. The parent of a school-age child reports that the child becomes frustrated when unable to
perform tasks well and often has temper tantrums and difficulty sleeping. Which disorder may
be considered in this child?
a. Generalized anxiety disorder (GAD)
b. Obsessive-compulsive disorder (OCD)
 c. Pediatric autoimmune neuropsychiatric disorder associated with streptococcal
infection (PANDAS)
d. Separation anxiety disorder (SAD)
ANS: A
GAD is characterized by over-concern about competence, significant self-consciousness,
irritability and tantrums, and poor sleep. OCD results in recurring thoughts, images, or
impulses. Patients with PANDAS have OCD- and Tourette-like symptoms. SAD causes
difficulties separating from caregivers and being away from home.

10. The parent of a school-age girl reports that the child has difficulty getting ready for school and
is often late because of a need to check and recheck whether her teeth are clean and her room
light has been turned off. What will the primary care pediatric nurse practitioner recommend
to this parent?
a. Cognitive-behavioral therapy
b. Deferral of treatment until symptoms worsen
c. Medication management with an SSRI
d. Referral to a child psychiatrist
ANS: A
Cognitive-behavioral therapy is used for mild to moderate symptoms of obsessive-compulsive
disorder (OCD). Children who have mild symptoms that do not interfere with their lives can
defer treatment, but this is not the case in this situation. Medication and referral to a child
psychiatrist are used for more severe symptoms.

11. A newly divorced mother of a toddler reports that the child began having difficulty sleeping
and nightmares along with exhibiting angry outbursts and tantrums 2 months prior. The
primary care pediatric nurse practitioner learns that the child refuses to play with usual
playmates and often spends time sitting quietly. What will the nurse practitioner do initially?
a. Ask the mother about the child’s relationship with the father.
b. Consult with a child psychiatrist to prescribe medications.
c. Recommend cognitive behavioral or psychodynamic therapy.
d. Refer the family to a child behavioral specialist for counseling.
ANS: A
The child exhibits signs of post traumatic stress disorder (PTSD). Because the parents are
newly divorced, the PNP should evaluate the child’s previous interactions with the father to
determine whether violence occurred. If PTSD is likely, referral to social service agencies
may be warranted. Pediatric mental health specialists may be involved once a diagnosis is
established and may order medications.

12. An adolescent has recently begun doing poorly in school and has stopped participating in
sports and other extracurricular activities. During the history interview, the adolescent reports
feeling tired, having difficulty concentrating, and experiencing a loss of appetite for the past
few weeks but cannot attribute these changes to any major life event. Which is an important
next step in managing this patient?
a. Administering a diagnostic rating scale for depression
b. Considering a short-term trial of an antidepressant medication
c. Determining suicidal ideation and risk of suicide
d. Referring the adolescent to a mental health specialist
 ANS: C
Because this adolescent exhibits clear signs of depression, the first goals of management are
to determine suicidal risk and to intervene to prevent suicide since the risk of suicide is
greatest during the first 4 weeks of a depressive episode. A diagnostic rating scale may help in
diagnosing the depression, but assessing suicide risk is a priority. Antidepressant medications
may be useful but are best initiated by a mental health specialist. The initial response in
adolescents should be to determine suicide risk to decide whether to admit to inpatient therapy
or refer to a mental health specialist.

13. An adolescent is diagnosed with major depression, and the mental health specialist has
prescribed fluoxetine. What other treatment is important to protect against suicide risk?
a. Addition of risperidone therapy
b. Cognitive-behavioral therapy
c. Family therapy
d. Hospitalization
ANS: B
Cognitive-behavioral therapy appears to have a protective effect against suicide and the best
treatment responses come from combinations of cognitive-behavioral therapy and selective
serotonin reuptake inhibitors (SSRIs). Risperidone and other antipsychotics are used if
psychosis is present to control those symptoms. Family therapy is useful but does not add
protection from suicide. Hospitalization is not the first-line treatment and is used for severe
exacerbations or suicide attempts.

14. A 13-year-old child has exhibited symptoms of mild depression for several weeks. The parent
reports feeling relieved that the symptoms have passed but concerned that the child now
seems to have boundless energy and an inability to sit still. What will the primary care
pediatric nurse practitioner do?
a. Administer an ADHD diagnostic scale and consider an
Attention-deficit/hyperactivity disorder (ADHD) medication.
b. Consult with a child psychiatrist to prescribe an antidepressant medication.
c. Reassure the parent that this behavior is common after mild depressive symptoms
d. Refer the child to a child psychiatrist for evaluation of bipolar disorder.
ANS: D
Children who have ADHD symptoms and depression should be evaluated by a child
psychiatrist for bipolar disorder. Medications are not appropriate until the disorder is correctly
diagnosed. Stimulant medications are not effective in treating bipolar disorder.
Antidepressants may potentiate manic responses. Providers should carefully evaluate and refer
any child treated for ADHD who does not respond to therapy or who experiences a sudden
worsening of agitation while using ADHD medications.

15. A toddler has begun hitting and biting other children at a day care center and is exhibiting
temper tantrums and bad language at home. The parent reports that these behaviors began
shortly after a sibling was born. What will the primary care pediatric nurse practitioner do?
a. Advise the parent that the child is exhibiting early symptoms of
Attention-deficit/hyperactivity disorder (ADHD).
b. Engage the parent in positive parenting strategies to facilitate appropriate child
coping.
c. Recommend evaluating the child for conduct or oppositional defiant disorder.
 d. Suggest putting the child in another day care center to ameliorate the problems.
ANS: B
Children with social aggression may exhibit the behaviors described above. When social
aggression is a response to acute stress, such as the birth of a sibling, the problem usually
resolves if parents use positive parenting strategies and facilitate developmentally appropriate
child coping efforts. These are not symptoms of ADHD. Conduct disorder (CD) symptoms
usually manifest in the preschool age. Oppositional defiant disorder (ODD) is characterized
by disobedience rather than aggressiveness. Moving the child to another day care or school
does not solve the problem.

16. A 14-year-old female comes to the clinic with amenorrhea for 3 months. A pregnancy test is
negative. The adolescent’s body weight is at 82% of expected for height and age. The mother
reports that her daughter often throws up and refuses to eat most foods. Which condition does
the primary care pediatric nurse practitioner suspect?
a. Anorexia nervosa
b. Bulimia nervosa
c. Depression
d. Substance abuse
ANS: A
Children with anorexia nervosa are usually underweight. Refusal to maintain body weight at
least 85% expected for age and height or failure to gain weight during growth periods so that
weight drops below 85% expected is one of the diagnostic criteria of anorexia. Some may
throw up frequently, but children with bulimia nervosa are generally average weight or
overweight. Depression and substance abuse may be comorbidities, but these signs are
consistent with anorexia nervosa.