STUDY GUIDE TO

Study Guide to Child and Adolescent Psychiatry is a question-and-answer

Child and Adolescent
PSYCHIATRY
companion that allows you to evaluate your mastery of the subject matter as you progress
through Dulcan’s Textbook of Child and Adolescent Psychiatry, Second Edition. The Study
Guide is made up of approximately 270 questions divided into 49 individual quizzes of 5–8
questions each that correspond to chapters in the textbook. Questions are followed by
an answer guide that references relevant text (including page numbers) in the textbook to
allow quick access to needed information. Each answer is accompanied by a discussion

Child and Adolescent PSYCHIATRY

that not only addresses the correct response but also explains why other responses are
not correct. A Companion to Dulcan’s Textbook of
The Study Guide’s companion, Dulcan’s Textbook of Child and Adolescent Psychiatry, Child and Adolescent Psychiatry, Second Edition
Second Edition, has been thoroughly updated to reflect significant changes to psychiat-
ric nomenclature and criteria in DSM-5. This new edition prunes older content while dis-

STUDY GUIDE TO
tilling and incorporating clinically relevant findings. Reorganized chapters feature tables
of selected diagnostic criteria from DSM-5 for quick reference.

Philip R. Muskin, M.D., M.A., is Professor of Psychiatry at CUMC, Consul-

tation-Liaison Psychiatry at Columbia University Medical Center; and faculty
member at the Columbia University Psychoanalytic Center.

Anna L. Dickerman, M.D, is Assistant Professor of Clinical Psychiatry at Weill

Cornell Medical College and Assistant Attending Psychiatrist at NewYork-Pres-
byterian Hospital.

Oliver M. Stroeh, M.D., is Clarice Kestenbaum, M.D. Assistant Professor of

Education and Training in the Division of Child & Adolescent Psychiatry (in
Psychiatry) at CUMC, Columbia University College of Physicians & Surgeons;
NewYork-Presbyterian Hospital; New York State Psychiatric Institute.

Dickerman
Muskin
Stroeh

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STUDY GUIDE TO
CHILD AND
ADOLESCENT
PSYCHIATRY

A Companion to
Dulcan’s Textbook of Child and
Adolescent Psychiatry,
Second Edition
STUDY GUIDE TO
CHILD AND
ADOLESCENT
PSYCHIATRY

A Companion to
Dulcan’s Textbook of Child and
Adolescent Psychiatry,
Second Edition

Edited by

Philip R. Muskin, M.D., M.A.

Anna L. Dickerman, M.D.
Oliver M. Stroeh, M.D.
Note: The authors have worked to ensure that all information in this book is accurate at
the time of publication and consistent with general psychiatric and medical standards,
and that information concerning drug dosages, schedules, and routes of administration
is accurate at the time of publication and consistent with standards set by the U.S. Food
and Drug Administration and the general medical community. As medical research and
practice continue to advance, however, therapeutic standards may change. Moreover,
specific situations may require a specific therapeutic response not included in this book.
For these reasons and because human and mechanical errors sometimes occur, we rec-
ommend that readers follow the advice of physicians directly involved in their care or
the care of a member of their family.
Books published by American Psychiatric Association Publishing represent the find-
ings, conclusions, and views of the individual authors and do not necessarily represent
the policies and opinions of American Psychiatric Association Publishing or the Ameri-
can Psychiatric Association.
If you wish to buy 50 or more copies of the same title, please go to www.appi.org/
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 Contents
Contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiii
Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xvii

P A R T I : Q u e s t i o n s

CH AP TER 1
The Process of Assessment and Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . .3

CH AP TER 2
Assessing Infants and Toddlers. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5

CH AP TER 3
Assessing the Preschool-Age Child . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7

CH AP TER 4
Assessing the Elementary School–Age Child . . . . . . . . . . . . . . . . . . . . . . . . .9

CH AP TER 5
Assessing Adolescents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11

CH AP TER 6
Neurological Examination, Electroencephalography,
Neuroimaging, and Neuropsychological Testing . . . . . . . . . . . . . . . . . . . . .13

CH AP TER 7
Intellectual Disability. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15

CH AP TER 8
Autism Spectrum Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17

CH AP TER 9
Neurodevelopmental Disorders
Specific Learning Disorder, Communication Disorders,
and Motor Disorders. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19

CH AP TER 10
Attention-Deficit/Hyperactivity Disorder . . . . . . . . . . . . . . . . . . . . . . . . . . . .21

CH AP TER 11
Oppositional Defiant Disorder and Conduct Disorder . . . . . . . . . . . . . . . . .23

CH AP TER 12
Substance Use Disorders and Addictions. . . . . . . . . . . . . . . . . . . . . . . . . . .25
CH AP TER 13
Depressive and Disruptive Mood Dysregulation Disorders . . . . . . . . . . . . . 27

CH AP TER 14
Bipolar Disorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

CH AP TER 15
Anxiety Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

CH AP TER 16
Posttraumatic Stress Disorder and Persistent Complex
Bereavement Disorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
CH AP TER 17
Obsessive-Compulsive Disorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

CH AP TER 18
Early Onset Schizophrenia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

CH AP TER 19
Psychiatric Aspects of Chronic Physical Disorders . . . . . . . . . . . . . . . . . . . 41

CH AP TER 20
Eating and Feeding Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
CH AP TER 21
Tic Disorders. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45

CH AP TER 22
Elimination Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47

CH AP TER 23
Sleep Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
CH AP TER 24
Evidence-Based Practice. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51

CH AP TER 25
Child Abuse and Neglect . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53

CH AP TER 26
Cultural and Religious Issues. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
CH AP TER 27
Youth Suicide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57

CH AP TER 28
Gender Dysphoria and Nonconformity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
CH AP TER 29
Aggression and Violence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .61

CH AP TER 30
Psychiatric Emergencies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .63

CH AP TER 31
Family Transitions
Challenges and Resilience . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .65
CH AP TER 32
Legal and Ethical Issues. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .67

CH AP TER 33
Telemental Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .69

CH AP TER 34
Principles of Psychopharmacology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .71

CH AP TER 35
Medications Used for Attention-Deficit/Hyperactivity Disorder . . . . . . . . . .73

CH AP TER 36
Antidepressants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .75

CH AP TER 37
Mood Stabilizers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .77

CH AP TER 38
Antipsychotic Medications. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .79
CH AP TER 39
Individual Psychotherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .81

CH AP TER 40
Parent Counseling, Psychoeducation, and Parent Support Groups . . . . . .83

CH AP TER 41
Behavioral Parent Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .85

CH AP TER 42
Family-Based Assessment and Treatment . . . . . . . . . . . . . . . . . . . . . . . . . .87

CH AP TER 43
Interpersonal Psychotherapy for Depressed Adolescents . . . . . . . . . . . . . .89

CH AP TER 44
Cognitive-Behavioral Treatment for Anxiety and Depression . . . . . . . . . . .91
CH AP TER 45
Motivational Interviewing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93

CH AP TER 46
Systems of Care, Wraparound Services, and Home-Based Services . . . . . 95

CH AP TER 47
Milieu Treatment
Inpatient, Partial Hospitalization, and Residential Programs . . . . . . . . . . . . 97
CH AP TER 48
School-Based Interventions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99

CH AP TER 49
Collaborating With Primary Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101

P a r t I I : A n s w e r G u i d e

CH AP TER 1
The Process of Assessment and Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . 107
CH AP TER 2
Assessing Infants and Toddlers. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113

CH AP TER 3
Assessing the Preschool-Age Child . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121

CH AP TER 4
Assessing the Elementary School–Age Child . . . . . . . . . . . . . . . . . . . . . . . 125
CH AP TER 5
Assessing Adolescents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129

CH AP TER 6
Neurological Examination, Electroencephalography,
Neuroimaging, and Neuropsychological Testing . . . . . . . . . . . . . . . . . . . . 133

CH AP TER 7
Intellectual Disability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139

CH AP TER 8
Autism Spectrum Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147

CH AP TER 9
Neurodevelopmental Disorders
Specific Learning Disorder, Communication Disorders,
and Motor Disorders. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153
CH AP TER 10
Attention-Deficit/Hyperactivity Disorder . . . . . . . . . . . . . . . . . . . . . . . . . . .157

CH AP TER 11
Oppositional Defiant Disorder and Conduct Disorder . . . . . . . . . . . . . . . .163

CH AP TER 12
Substance Use Disorders and Addictions. . . . . . . . . . . . . . . . . . . . . . . . . .169

CH AP TER 13
Depressive and Disruptive Mood Dysregulation Disorders . . . . . . . . . . . .173

CH AP TER 14
Bipolar Disorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .179

CH AP TER 15
Anxiety Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .183

CH AP TER 16
Posttraumatic Stress Disorder and Persistent Complex
Bereavement Disorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .187

CH AP TER 17
Obsessive-Compulsive Disorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .197
CH AP TER 18
Early Onset Schizophrenia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .203

CH AP TER 19
Psychiatric Aspects of Chronic Physical Disorders . . . . . . . . . . . . . . . . . .209

CH AP TER 20
Eating and Feeding Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .213
CH AP TER 21
Tic Disorders. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .217

CH AP TER 22
Elimination Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .223

CH AP TER 23
Sleep Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .227
CH AP TER 24
Evidence-Based Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .235

CH AP TER 25
Child Abuse and Neglect . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .241
CH AP TER 26
Cultural and Religious Issues. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 245

CH AP TER 27
Youth Suicide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 251

CH AP TER 28
Gender Dysphoria and Nonconformity . . . . . . . . . . . . . . . . . . . . . . . . . . . . 257

CH AP TER 29
Aggression and Violence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 261

CH AP TER 30
Psychiatric Emergencies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 265

CH AP TER 31
Family Transitions
Challenges and Resilience . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 271

CH AP TER 32
Legal and Ethical Issues. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 277

CH AP TER 33
Telemental Health. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 281

CH AP TER 34
Principles of Psychopharmacology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 287

CH AP TER 35
Medications Used for Attention-Deficit/Hyperactivity Disorder. . . . . . . . . 291
CH AP TER 36
Antidepressants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 295

CH AP TER 37
Mood Stabilizers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 299

CH AP TER 38
Antipsychotic Medications. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 303

CH AP TER 39
Individual Psychotherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 307

CH AP TER 40
Parent Counseling, Psychoeducation, and Parent Support Groups . . . . . 311

CH AP TER 41
Behavioral Parent Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 315
CH AP TER 42
Family-Based Assessment and Treatment . . . . . . . . . . . . . . . . . . . . . . . . . 321

CH AP TER 43
Interpersonal Psychotherapy for Depressed Adolescents. . . . . . . . . . . . . 325

CH AP TER 44
Cognitive-Behavioral Treatment for Anxiety and Depression . . . . . . . . . . 329

CH AP TER 45
Motivational Interviewing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 337

CH AP TER 46
Systems of Care, Wraparound Services, and Home-Based Services . . . . 341

CH AP TER 47
Milieu Treatment
Inpatient, Partial Hospitalization, and Residential Programs . . . . . . . . . . . 345

CH AP TER 48
School-Based Interventions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 349

CH AP TER 49
Collaborating With Primary Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 353
 Contributors
Nicole C. Allen, M.D.
Attending Psychiatrist, Lenox Hill Hospital/Northwell Health

Alexandra Canetti, M.D.

Assistant Professor of Psychiatry at CUMC, Columbia University College of Physicians
& Surgeons; NewYork-Presbyterian Hospital

Shannon Gulliver Caspersen, M.D.

Clinical Instructor, Weill Cornell Medical College; NewYork-Presbyterian Hospital

Ashley K. Crumby, M.D.

Assistant Professor of Clinical Psychiatry, Weill Cornell Medical College; NewYork-
Presbyterian Hospital

Shannon Delaney, M.D.

Postdoctoral Research Fellow, Columbia University College of Physicians & Surgeons;
New York State Psychiatric Institute

Anna L. Dickerman, M.D.

Assistant Professor of Clinical Psychiatry; Assistant Attending Psychiatrist, Weill Cor-
nell Medical College; NewYork-Presbyterian Hospital

Helen T. Ding, M.D.

Assistant Professor of Clinical Psychiatry, Weill Cornell Medical College; NewYork-
Presbyterian Hospital

Eve Khlyavich Freidl, M.D.

Assistant Professor of Psychiatry at CUMC, Columbia University College of Physicians
& Surgeons; NewYork-Presbyterian Hospital

Maalobeeka Gangopadhyay, M.D.

Assistant Professor of Psychiatry at CUMC, Columbia University College of Physicians
& Surgeons; NewYork-Presbyterian Hospital

Heather Goodman, M.D.

xiii
Michael B. Grody, M.D.
Assistant Professor of Clinical Psychiatry, Weill Cornell Medical College; NewYork-
Presbyterian Hospital

Kathleen Jung, M.D.

Assistant Professor of Psychiatry at CUMC, Columbia University College of Physicians
& Surgeons; NewYork-Presbyterian Hospital

Sarah Richards Kim, M.D.

Clinical Assistant Professor of Psychiatry, Bellevue Hospital/NYU Langone Medical Center

Denise Leung, M.D.

Assistant Professor of Psychiatry at CUMC, Columbia University College of Physicians
& Surgeons; NewYork-Presbyterian Hospital

Annie Sze Yan Li, M.D.

Assistant Professor in Clinical Psychiatry, Weill Cornell Medical College; NewYork-Presby-
terian Hospital

Maria G. Master, J.D., M.D.

Assistant Professor of Clinical Psychiatry and Medical Ethics, Weill Cornell Medical Col-
lege; NewYork-Presbyterian Hospital

Megan M. Mroczkowski, M.D.

Assistant Professor of Psychiatry at CUMC, Columbia University College of Physicians
& Surgeons; NewYork-Presbyterian Hospital

Philip R. Muskin, M.D., M.A.

Professor of Psychiatry at CUMC, Consultation-Liaison Psychiatry at Columbia Univer-
sity Medical Center; Faculty, Columbia University Psychoanalytic Center

Siobhan O’Herron, M.D.

Assistant Professor of Clinical Psychiatry, Weill Cornell Medical College; NewYork-Presby-
terian Hospital

Lakshmi Reddy, M.D.

Assistant Professor of Clinical Psychiatry, Weill Cornell Medical College; NewYork-Presby-
terian Hospital

Adriana E. Rego, M.D.

Assistant Professor of Psychiatry at CUMC, Columbia University College of Physicians
& Surgeons; NewYork-Presbyterian Hospital; NYU Child Study Center

Rebecca Rendleman, M.D.

Assistant Professor of Clinical Psychiatry, Weill Cornell Medical College; NewYork-
Presbyterian Hospital

xiv | Contributors
Anna Halperin Rosen, M.D.
Assistant Professor of Clinical Psychiatry, Weill Cornell Medical College; NewYork-
Presbyterian Hospital

Susan Samuels, M.D.

Assistant Professor of Clinical Psychiatry and Pediatrics, Weill Cornell Medical College;
NewYork-Presbyterian Hospital

Mariana Schmajuk, M.D.

Clinician Educator, Psychosomatic Medicine Service, Stanford Hospital and Clinic

Jessica Simberlund, M.D.

Child and Adolescent Psychiatry Resident, NewYork-Presbyterian Hospital

Alma Spaniardi, M.D.

Assistant Professor of Clinical Psychiatry, Weill Cornell Medical College; NewYork-
Presbyterian Hospital

Katharine Stratigos, M.D.

Assistant Clinical Professor of Psychiatry; Whitaker Developmental Neuropsychiatry
Scholar, Columbia University College of Physicians & Surgeons; NewYork-Presbyterian
Hospital

Oliver M. Stroeh, M.D.

Clarice Kestenbaum, M.D. Assistant Professor of Education and Training in the Division
of Child & Adolescent Psychiatry (in Psychiatry) at CUMC, Columbia University Col-
lege of Physicians & Surgeons; NewYork-Presbyterian Hospital; New York State Psychi-
atric Institute

Meredith Weiss, M.D.

Assistant Professor of Clinical Psychiatry, Weill Cornell Medical College; NewYork-
Presbyterian Hospital

M. Carolina Zerrate, M.D.

Assistant Professor of Psychiatry at CUMC, Columbia University College of Physicians
& Surgeons; New York–Presbyterian Hospital

Disclosure of competing interests: The volume editors have indicated that they have no fi-
nancial interests or other affiliations that represent a competing interest with their contributions
to this book.

Contributors | xv
 Preface

T his self-examination guide is a companion to, not a replacement for, Dulcan’s Textbook
of Child and Adolescent Psychiatry, Second Edition. Dulcan’s textbook covers the full range
of issues related to the diverse group of pediatric patients from early childhood through
adolescence. It will prepare readers to understand the assessment and treatment of these
patients. The study guide is organized around each chapter in the textbook. As you work
through this self-examination book, let it guide you to focus on chapters in the textbook as
a path to your self-education. Some questions will seem obvious or easy, whereas others
will be quite difficult. We have endeavored to use the style of question writing found in
certification examinations; however, this is not a board preparation book.
The contributors to this book are primarily from the NewYork-Presbyterian Hospital
Child and Adolescent Psychiatry Residency Training Program and the Columbia Uni-
versity Medical Center Psychosomatic Medicine Fellowship Program. They are a group
of fellows and faculty with an exceptionally broad range of experience and expertise who
undertook the difficult task of writing the questions. The contributors have graciously
donated the proceeds from this book to charitable foundations dedicated to mental
health.
Editors
Philip R. Muskin, M.D., M.A.
Anna L. Dickerman, M.D.
Oliver M. Stroeh, M.D.

xvii
 PART I

Questions
 C H A P T E R 1

The Process of Assessment

and Diagnosis
1.1 Which of the following is used to assess normality and deviation from normality
of what the average expectable child will be like at any given age?

A. Mentalization.
B. Developmental framework.
C. Biopsychosocial model.
D. Cognitive restructuring.

1.2 How do adult assessments differ from child assessments?

A. In adult assessments, the prime source of information is typically the patient;

in child assessments, the information is typically provided by the child and his
or her teacher.
B. With adults, the interchange between psychiatrist and adult patient is generally
verbal; with youth of any age, the role of play is central in the evaluation process.
C. Adults typically are brought to the evaluation and rarely seek it out, whereas
children generally participate volitionally in the evaluation.
D. With adults, their usually positive expectations of seeing a psychiatrist pro-
vide motivation for the initial phases of evaluation; with children, most do not
see the doctor as particularly helpful, and therefore the psychiatrist frequently
has to work much harder to establish a working relationship with the child.

1.3 Why do child psychiatrists generally see contacting the school as a necessary and
vital part of a complete evaluation of a child or adolescent?

A. Because data regarding the child’s academic status and progress are needed.
B. Because information regarding the child’s social relatedness to peers (but not
adults) is needed.
C. Because information regarding the teachers’ comparisons of the child to his or
her older-aged peers is helpful.
D. Because school staff members are the major source of data regarding how the
child views himself.

3
1.4 When using the temporal axis schema proposed by Ebert et al. (2000) to organize
a formulation, which factors are defined as stressors that test the individual’s cop-
ing mechanisms and cause signs and symptoms to occur?

A. Biological factors.
B. Perpetuating factors.
C. Psychological factors.
D. Precipitating factors.

1.5 Which of the following is a purpose of the interpretive or feedback interview?

A. To inform the parents alone of what the clinician has found.

B. To inform the parents and child of what the clinician has decided will be done
to address the issues for which they came.
C. To help parents understand that human behavior, especially children’s behav-
ior, typically is shaped by a single cause for which intervention exists.
D. To help parents realistically appraise their situation and their child.

4 | The Process of Assessment and Diagnosis—Questions

 C H A P T E R 2

Assessing Infants and

Toddlers
2.1 Which of the following most closely predicts an infant or toddler’s ability to re-
main resilient in the face of stress?

A. Environmental factors.
B. Caregiving relationships.
C. Intrinsic risk factors.
D. Biological processes.

2.2 At what developmental age does separation from caregivers activate the child’s
attachment system?

A. Birth to 2 months.
B. 2–7 months.
C. 7–9 months.
D. 18–36 months.

2.3 What does the Insightfulness Assessment (IA) measure?

A. Parent’s ability to take the infant’s perspective.

B. Parent’s primary defensive strategy.
C. Parent’s understanding of his or her child and of the relationships they share.
D. Multiple domains of the parent–child relationship, including reciprocal emo-
tions.

2.4 What assessment tool can best provide information about dyadic emotional reg-
ulation for infants ages 3–6 months?

A. Diagnostic Infant Preschool Structured Interview.

B. Early Childhood Screening Assessment.
C. Child Behavior Checklist.
D. Still-face paradigm.

5
2.5 What is the best studied influence on parent report measures?

A. Maternal depression.
B. Child behaviors.
C. Child development.
D. Parental sensitivity.

6 | Assessing Infants and Toddlers—Questions

 C H A P T E R 3

Assessing the
Preschool-Age Child
3.1 Which of the following represents the ideal format for conducting a comprehen-
sive assessment of a preschool-age child?

A. One session with the child and primary caregiver.

B. Several sessions on different days with the child and with only the primary
caregiver.
C. Several sessions on the same day with the child and with more than one care-
giver whenever possible.
D. Several sessions on different days with the child and with more than one care-
giver whenever possible.

3.2 Which types of observations pertaining to the caregiver–child dyad are most in-
formative in the assessment of the preschool-age child?

A. Unstructured (free-play) and semistructured observations.

B. Very structured and structured observations.
C. Structured and semistructured observations.
D. Structured and unstructured (free-play) observations.

3.3 Which of the following is true regarding mental health disorders in preschool-age
children?

A. Externalizing disorders prompt caregivers to seek care.

B. Anxiety disorders predominate in preschool clinic samples.
C. Preschool diagnoses have been shown to be transient and do not warrant early
intervention.
D. Externalizing disorders are more distressing to the child and family than inter-
nalizing disorders.

7
3.4 Which of the following is true about obtaining the comprehensive history of the
preschool-age child?

A. The developmental history does not include milestone achievements in sen-

sory, social, and emotional domains because they are difficult to quantify.
B. Comprehensive history from primary caregivers occurs with the child present
to avoid damaging the rapport with the child.
C. Details of pregnancy and perinatal history are essential and often relevant to
the chief complaint and current mental state.
D. Information should be obtained from only one caregiver.

3.5 Which is the most beneficial approach when giving feedback to parents regarding
the assessment of their preschool-age child?

A. Begin before the parents speak.

B. Avoid addressing any parental resistance.
C. Serve as a collaborator.
D. Ignore any ambivalence displayed by the parent.

3.6 Which of the following is true regarding use of play in the assessment of the pre-
school-age child?

A. Direct interviewing is the most effective method for assessing the internal emo-
tional state of the preschooler.
B. Observation of the child in play is essential to the mental status examination
of the preschool-age child.
C. If negative play themes emerge, the clinician should intervene to prevent
harm.
D. Play is universal and not influenced by variables such as cultural values.

8 | Assessing the Preschool-Age Child—Questions

 C H A P T E R 4

Assessing the
Elementary School–Age
Child
4.1 Which of the following statements is true regarding suicidal thinking and behav-
iors in school-age children?

A. Inquiry regarding suicidal thinking and behavior may cause a child to adopt
this thinking and behavior.
B. Suicidal thinking and behaviors do not exist in this age group.
C. It is imperative to evaluate for past and current history of suicidal ideation and
suicide plans/attempts.
D. It is not imperative to evaluate for nonsuicidal self-injurious ideation and be-
haviors.

4.2 Which of the following is the best approach for interviewing a school-age child?

A. Ask the child about any history of abuse in the presence of his or her parents.
B. Interview the parent and child together when discussing family history of
mental health illness.
C. Meet with the child alone to ask about his or her self-esteem.
D. Ensure that parents get to discuss all issues with the child present.

4.3 What is the most appropriate step to take if a parent or guardian opts to limit the
gathering of collateral information from a previous provider?

A. Communicate freely with the previous provider anyway, because there is no

need to obtain consent before contacting previous providers.
B. Take no action, because gathering collateral information is not an important
part of a comprehensive evaluation.
C. Take no action, because most parents do not agree to such communication with
previous providers.
D. Honor the parent’s preferences, and perhaps revisit the issue as the working re-
lationship grows.

9
4.4 What principles should a clinician consider when speaking to school-age children?

A. A general rule in asking children questions is to use “why” questions.

B. Children’s lack of elaborate responses is indicative of their unwillingness to
speak.
C. School-age children generally do not spontaneously discuss many of the mat-
ters that are important to review during a psychiatric assessment.
D. Offering answer choices is not a good strategy.

4.5 After the clinician has completed a psychiatric evaluation and organized the in-
formation in a biopsychosocial formulation, what is the best way to present the
findings to the family?

A. Concentrate on the psychopathology of the child and family and do not discuss
their strengths.
B. List the symptoms and explain the possible contributing factors.
C. Omit difficult topics such as family relations as contributors.
D. Meet separately with the parent and child.

10 | Assessing the Elementary School–Age Child—Questions

 C H A P T E R 5

Assessing Adolescents
5.1 Which of the following is an important prerequisite to beginning an assessment of
an adolescent?

A. Rapport building.
B. Data collection.
C. Establishing custody or guardianship.
D. Understanding the adolescent’s interests and strengths.

5.2 What is the proper balance between confidentiality for an adolescent and suffi-
cient communication with the parent?

A. Everything the adolescent shares will be kept confidential.

B. It is the parent’s right to know every detail that the adolescent shares.
C. An adolescent may assume everything he or she says will be communicated
directly to the parent.
D. The parent should have an overview of problems unless the adolescent would
be at risk of harm.

5.3 What technique should the interviewer use to move forward if the adolescent is
not engaged in the interview?

A. Data collection.
B. Motivational enhancement techniques.
C. Discussing the adolescent’s perception of why he or she has been brought for
evaluation.
D. Closed-ended questions.

5.4 Which aspect of family functioning includes the elements of adaptability and de-
gree of cohesion among members of the family?

A. Family communication.
B. Family beliefs.
C. Family structure.
D. Family regulatory processes.

11
5.5 What is the first aspect of focus when presenting the findings of an adolescent as-
sessment to the family?

A. The strengths of both the adolescent and the parents.

B. The problems areas uncovered during the assessment.
C. A formulation of how the problems developed and are perpetuated.
D. The proposed plan for treatment.

12 | Assessing Adolescents—Questions
 C H A P T E R 6

Neurological Examination,
Electroencephalography,
Neuroimaging, and
Neuropsychological Testing
6.1 Which part of the neurological examination is least objective in nonverbal and/or
young patients?

A. Gait.
B. Motor examination.
C. Sensory examination.
D. Cranial nerve assessment.

6.2 Which of the following is part of coordination assessment?

A. Observing the patient’s sitting posture.

B. Having the patient walk on an imaginary tightrope.
C. Measuring the patient’s height, weight, and head circumference.
D. Having the patient chew and swallow.

6.3 What is the finding or findings for a lower motor neuron lesion?

A. Spastic paralysis.
B. Muscle hypertonia.
C. Babinski reflex positive.
D. Muscle fasciculations and fibrillations.

6.4 Which of the following electroencephalographic (EEG) findings is indicative of

seizure activity in a school-age child?

A. Alpha wave pattern.

B. High-amplitude slowing.

13
 C. Theta wave pattern.
D. Spike and slow-wave discharge.

6.5 What kind of neuroimaging is used to preoperatively evaluate patients with epi-
lepsy to determine hemispheric language dominance and for surgical planning?

A. Functional magnetic resonance imaging (fMRI).

B. Computed tomography (CT).
C. Magnetic resonance spectroscopy (MRS).
D. Positron emission tomography (PET).

6.6 Which brain area is the last one to mature?

A. Somatosensory cortex.
B. Prefrontal cortex.
C. Visual cortex.
D. Temporal cortex.

6.7 Which of the following is an indication for neuropsychological testing?

A. To examine the emotional basis of functional complaints (e.g., poor memory).

B. To assess unstable mental status.
C. To assess prognosis in functioning in relation to treatment.
D. To assess a patient with an uncontrolled treatable psychiatric disorder.

6.8 What abnormal electroencephalographic pattern correlates with encephalopathic

states?

A. Spikes.
B. Alpha waves.
C. Global suppression.
D. Beta waves.

14 | Neurological Examination, EEG, and Neuroimaging—Questions

 C H A P T E R 7

Intellectual Disability
7.1 What is the strongest basis for determining the level of severity of a patient’s in-
tellectual disability?

A. Severity levels are determined by the underlying congenital syndrome leading

to intellectual disability.
B. Severity levels are determined by adaptive functioning.
C. Severity levels are determined by intelligence quotient (IQ).
D. Severity levels are determined by language abilities.

7.2 Which of the following is the correct diagnosis for someone who becomes cogni-
tively disabled after age 18 years?

A. Intellectual disability.
B. Learning disorder.
C. Dementia.
D. Mental retardation.

7.3 What is the most common form of intellectual disability that the clinician will en-
counter in practice?

A. Mild.
B. Moderate.
C. Severe.
D. Profound.

7.4 What is the strongest predictor for intellectual disability of unknown etiology?

A. Low birth weight.

B. Gender.
C. Socioeconomic status.
D. Multiple births (twins).

15
7.5 Which of the following characteristics most closely describe an individual with
fetal alcohol spectrum disorder?

A. Intellectual disability, tremor/ataxia syndrome, increased risk for psychopa-

thology, and autistic features.
B. Intellectual disability, muscle hypotonia, short stature, distinctive facial ap-
pearance, and obesity.
C. Intellectual disability, seizures, motor stereotypies, breathing abnormalities,
ataxia, and growth failure.
D. Intellectual disability, facial anomalies, prenatal and/or postnatal growth retarda-
tion, learning deficits, and attention problems.

7.6 What are the current recommendations for genetic testing in individuals with in-
tellectual disability without a definite diagnosis?

A. Genetic testing is recommended regardless of whether dysmorphology, family

history, or other clinical features are present.
B. Genetic testing is recommended if dysmorphology is present.
C. Genetic testing is recommended if there is a strong family history or clinical
features are suggestive of a genetic syndrome.
D. Genetic testing is recommended if either a family history or dysmorphology
is present.

16 | Intellectual Disability—Questions
 C H A P T E R 8

Autism Spectrum Disorders

8.1 What is the outcome of having DSM-5 consolidate multiple prior diagnoses (e.g.,
Asperger’s disorder and pervasive developmental disorder not otherwise speci-
fied [PDD-NOS]) under the single umbrella term autism spectrum disorder (ASD)?

A. Children with PDD-NOS are typically not eligible to meet ASD criteria.
B. There is a loss of specificity and reliability in diagnosis.
C. There is an emphasis on ASD as a continuum.
D. Social (pragmatic) communication disorder is included under the new ASD
criteria as well.

8.2 Which of the following clinical scenarios is most likely to prompt parents’ concern
about delays in their child’s development?

A. The child is not using facial expressions or gestures or showing enthusiasm

when greeting others.
B. The child is not standing by 15 months.
C. The child is not making meaningful eye contact or directing another person’s
attention to things.
D. The child is not using words by 15 months.

8.3 Which two instruments are universally recognized as the most valid diagnostic
instruments available to diagnose autism?

A. Childhood Autism Rating Scale (CARS) and the Autism Diagnostic Observation
Schedule—Generic (ADOS-G).
B. Modified Checklist for Autism in Toddlers (M-CHAT) and the Autism Diagnos-
tic Observation Schedule—Generic (ADOS-G).
C. Social Communication Questionnaire (SCQ) and the Autism Diagnostic Ob-
servation Schedule—Generic (ADOS-G).
D. Autism Diagnostic Interview—Revised (ADI-R) and the Autism Diagnostic Ob-
servation Schedule—Generic (ADOS-G).

17
8.4 What genetic test should be offered to individuals with autism?

A. Rett syndrome.
B. 22q11.2 deletion syndrome (velocardiofacial syndrome).
C. Angelman syndrome.
D. Fragile X syndrome.

8.5 Which of the following behavioral and psychosocial treatments has the greatest
evidence base for autism spectrum disorders?

A. Social Stories.
B. Developmental, Individual-Difference, Relationship-Based Approach (DIR).
C. Applied Behavioral Analysis (ABA).
D. Relationship Development Intervention (RDI).

18 | Autism Spectrum Disorders—Questions

 C H A P T E R 9

Neurodevelopmental
Disorders
Specific Learning Disorder,
Communication Disorders, and
Motor Disorders
9.1 What is the most prevalent DSM-5 learning disorder (LD) in children receiving
special education services?

A. Mathematics disorder.
B. Dysgraphia.
C. Disorder of written expression.
D. Reading disorder.

9.2 With regard to defining learning disorders (LDs), which of the following statements
is true?

A. The federal government’s definition used by classroom teachers classifies LDs

in the same way that DSM-5 does.
B. The threshold for positive identification of LDs and the definition and catego-
ries of special education vary from state to state.
C. In DSM-5 the LD definitions were not changed from DSM-IV.
D. In defining LDs, the various categorical systems often agree.

9.3 Which of the following is the unexpected disturbance in the normal patterns and
flow of speech?

A. Expressive language disorder.

B. Receptive language disorder.
C. Childhood-onset fluency disorder.
D. Speech sound disorder.

19
9.4 In addition to social (pragmatic) communication disorder, which of the following
should be included on the differential diagnosis of a child presenting with prag-
matic language deficits?

A. Attention-deficit/hyperactivity disorder (ADHD).

B. Speech sound disorder.
C. Childhood-onset fluency disorder.
D. Developmental coordination disorder.

9.5 Which of the following cognitive skills is the last and most complex skill to develop?

A. Number sense.
B. Phonological awareness.
C. Word recognition.
D. Written expression.

20 | Neurodevelopmental Disorders—Questions
 C H A P T E R 1 0

Attention-Deficit/
Hyperactivity Disorder

10.1 What change has been made in the diagnostic criteria for attention-deficit/hyper-
activity disorder (ADHD) in DSM-5?

A. Symptoms can also be accounted for by some other psychiatric condition.

B. Several symptoms are required to be present before age 12 years.
C. Individual symptom descriptions have been narrowed.
D. ADHD cannot be diagnosed concurrently with autism spectrum disorder.

10.2 Which of the following is a true statement regarding the genetic contribution to
attention-deficit/hyperactivity disorder (ADHD)?

A. A large percentage of the variance in ADHD traits is attributable to genetics.

B. Heritability rates in ADHD minimize the effect of the environment.
C. A gene variant with genomewide significance has been discovered.
D. Copy number variants are found less often in patients with ADHD.

10.3 Which of the following is an established risk factor for the development of
ADHD?

A. Maternal smoking during pregnancy.

B. Post-term pregnancy.
C. Low Apgar scores.
D. Small size for gestational age.

10.4 Which brain system identified in functional magnetic resonance imaging (fMRI)
studies is specialized for detecting relevant stimuli and novelty, and is also a key
region for response inhibition?

A. Ventral striatum.
B. Temporoparietal junction and inferior frontal cortex.

21
 C. Anterior cingulate cortex.
D. Dorsolateral prefrontal cortex and intraparietal sulcus.

10.5 What is an essential element in diagnosing attention-deficit/hyperactivity disorder

(ADHD)?

A. Psychological testing.
B. Sleep study.
C. Interview with parent.
D. Neurological examination.

10.6 What is the principal treatment for the core symptoms of attention-deficit/hyper-
activity disorder (ADHD)?

A. Pharmacotherapy.
B. Behavioral treatment.
C. Neurofeedback.
D. Artificial food color elimination diet.

22 | Attention-Deficit/Hyperactivity Disorder—Questions
 C H A P T E R 1 1

Oppositional Defiant
Disorder and
Conduct Disorder
11.1 Which of the following psychiatric disorders is the most common comorbid con-
dition found with oppositional defiant disorder (ODD)?

A. Mood disorder.
B. Attention-deficit/hyperactivity disorder (ADHD).
C. Separation anxiety disorder.
D. Obsessive-compulsive disorder.

11.2 Which of the following environmental factors is correlated with increased risk for
oppositional defiant disorder (ODD)?

A. Fair and consistent limit setting.

B. Higher socioeconomic status.
C. Domestic violence.
D. High family cohesion.

11.3 Which of the following is an evidence-based treatment for oppositional defiant

disorder (ODD)?

A. Stimulants.
B. Atypical antipsychotics.
C. Psychodynamic psychotherapy.
D. Parent management training.

11.4 Which of the following is true of childhood-onset conduct disorder (CD) when com-
pared with adolescent-onset CD?

A. Patients with childhood-onset CD are more likely to have higher IQ.

B. Those with childhood-onset CD are more likely to have comorbid attention-
deficit/hyperactivity disorder (ADHD).

23
 C. Those with childhood-onset CD are less likely to have co-occurring neuropsy-
chiatric disorders.
D. Those with childhood-onset CD tend to have less severe disruptive and anti-
social behaviors into adolescence and adulthood.

11.5 Which of the following statements is true regarding increased risk for onset or fur-
ther development of conduct disorder (CD)?

A. Intrauterine exposure to toxic substances increases the risk of CD.

B. Researchers have concluded that CD does not have a genetic basis for inheri-
tance and its development is purely environmental.
C. Low intelligence is associated with conduct problems, but verbal abilities are
not.
D. Children who have been sexually abused are more likely to develop CD, but
the same is not true of physical abuse and neglect.

24 | Oppositional Defiant Disorder and Conduct Disorder—Questions

 C H A P T E R 1 2

Substance Use Disorders

and Addictions
12.1 Which of the following statements best explains increased vulnerability to emer-
gence of a substance use disorder (SUD) during adolescence?

A. Adolescence is characterized by an imbalance between early emerging sub-

cortical systems that may express reactivity to motivational stimuli and later-
developing cognitive control regions, which include executive functions.
B. The risk of progression to an SUD is only associated with the use of illegal sub-
stances.
C. Compromise of reward mechanisms does not affect the risk for SUDs.
D. During adolescence, cognitive control processes are less vulnerable to incentive-
based (reward) modulation.

12.2 What constitutes the major change between DSM-IV and DSM-5 criteria for classi-
fying substance use?

A. The new DSM-5 diagnosis of substance use disorder (SUD) requires a thresh-
old of five physical signs and symptoms from the former DSM-IV criterion
lists for both abuse and dependence.
B. Severity specifiers in DSM-5 but not in DSM-IV are determined by the number
of substances abused.
C. DSM-IV diagnoses of abuse and dependence are replaced in DSM-5 by a single
diagnosis of SUD, specified by the type of substance involved.
D. The terms addiction and chemical dependency are operationally defined in DSM-5
but not in DSM-IV.

12.3 Which of the following pharmacological agents for the treatment of attention-
deficit/hyperactivity disorder has the highest potential for abuse and diversion?

A. Bupropion.
B. Atomoxetine.
C. Osmotic-release oral system methylphenidate.
D. α-Agonists.

25
12.4 Which of the following therapies has the most empirical support for use in the treat-
ment of adolescent substance use disorders (SUDs)?

A. Motivational interviewing.
B. Cognitive-behavioral therapy.
C. Contingency management.
D. Family therapies.

12.5 Which of the following circumstances would force a clinician to break confidential-
ity on behalf of an adolescent patient?

A. A positive urine toxicology test.

B. Illegal behavior, such as selling drugs.
C. Disclosure of recent sexual abuse.
D. Parental request for details on specific behaviors.

26 | Substance Use Disorders and Addictions—Questions

 C H A P T E R 1 3

Depressive and Disruptive

Mood Dysregulation
Disorders
13.1 A 15-year-old female with a history of major depressive disorder (MDD), recurrent,
severe, continues to be symptomatic in spite of 16 weeks of treatment with fluoxe-
tine 40 mg/day. Which of the following would be the next appropriate step?

A. Switch to another selective serotonin reuptake inhibitor (SSRI).

B. Switch to venlafaxine.
C. Switch to venlafaxine and add cognitive-behavioral therapy (CBT).
D. Continue to increase the fluoxetine dosage.

13.2 A 17-year-old male presents with a low mood that has lasted for 1 month follow-
ing the sudden death of his mother in a car accident. Which of the following
would indicate that he may be experiencing a major depressive episode?

A. He has thoughts about death that are primarily related to joining his deceased
mother.
B. His grief has decreased in intensity and occurs in waves that are associated with
thoughts of his mother.
C. He ruminates about the death of his mother and persistently feels as if he is di-
rectly responsible for her death, contributing to feelings of worthlessness.
D. His feelings consist of emptiness and loss as a result of his mother’s death.

13.3 A 16-year-old youth presents with a moderate to severe depressive episode char-
acterized by low mood, hopelessness, insomnia, weight loss, decreased concentra-
tion, and suicidal ideation that has been triggered as a result of conflictual family
interactions. Which of the following two psychotherapeutic modalities have the
greatest evidence base from randomized controlled trials (RCTs) for treatment of
depressed adolescents?

A. Interpersonal psychotherapy and psychodynamic psychotherapy.

B. Cognitive-behavioral therapy (CBT) and interpersonal psychotherapy.

27
 C. Systemic behavioral family therapy and psychodynamic psychotherapy.
D. Cognitive-behavioral therapy and systemic behavioral family therapy.

13.4 Which condition can coexist with a diagnosis of disruptive mood dysregulation
disorder (DMDD)?

A. Oppositional defiant disorder.

B. Attention-deficit/hyperactivity disorder.
C. Intermittent explosive disorder.
D. Bipolar disorder.

13.5 A 14-year-old male presents with low mood and irritability for the past 4 months
with symptoms of somatic complaints, excessive worries about his health, insom-
nia, low energy, poor concentration, suicidal ideation, and low self-esteem. Which
of the following would be the most appropriate diagnosis?

A. Major depressive disorder (MDD) with mixed features.

B. MDD with anxious distress.
C. Persistent depressive disorder.
D. MDD with atypical features.

28 | Depressive and Disruptive Mood Dysregulation Disorders—Questions

 C H A P T E R 1 4

Bipolar Disorder
14.1 Which of the following DSM-IV Criterion B symptoms has now been moved to
the DSM-5 Criterion A of “abnormally and persistently elevated, expansive, or ir-
ritable mood”?

A. Inflated self-esteem or grandiosity.

B. Decreased need for sleep.
C. Persistently increased activity or energy.
D. Flight of ideas or subjective experiences that thoughts are racing.

14.2 Which of the following is the most common comorbid disorder in children with
mania?

A. Autism spectrum disorder.

B. Cannabis use disorder.
C. Alcohol use disorder.
D. Attention-deficit/hyperactivity disorder (ADHD).

14.3 Which of the following rates most accurately represents the risk of mania in high-
risk offspring in adulthood?

A. 60%.
B. 5%.
C. 35%.
D. 20%.

14.4 Which of the following is associated with a better prognosis following an episode
of mania in youth?

A. Older age at onset of mania.

B. Higher rates of comorbid conditions.
C. History of physical or sexual abuse.
D. Higher rates of psychiatric disorders in parents.

29
14.5 Which of the following medications has shown the largest effect for the acute treat-
ment of mania/mixed mania in children and adolescents?

A. Lithium.
B. Divalproex.
C. Risperidone.
D. Oxcarbazepine.

30 | Bipolar Disorder—Questions
 C H A P T E R 1 5

Anxiety Disorders
15.1 A 16-year-old reports increased anxiety for the last 6 months in anticipation of his
upcoming second attempt on the college entrance examination, scheduled in 2
days. He has increased difficulty falling asleep, has felt more on edge, and worries
what his peers think of him. He also worries about getting into college, his health,
and the health of his family. This teen is struggling with which of the following
issues?

A. Generalized anxiety disorder.

B. Specific phobia.
C. Social anxiety disorder.
D. Separation anxiety disorder.

15.2 Which of the following medications is considered the first-line psychopharmaco-

logical treatment for preschool-age children with separation anxiety disorder,
generalized anxiety disorder, selective mutism, or specific phobia after a failed 12-
week trial of psychotherapy?

A. Paroxetine.
B. Imipramine.
C. Fluoxetine.
D. Clonazepam.

15.3 A 7-year-old boy worries that his mother will die while he is in school or that he
will get lost and never see his mother again. The boy refuses to attend school, is
often sick in the nurse’s office when he is in school, and refuses to go for sleepovers
at friends’ and relatives’ houses without his mother. This presentation is most
consistent with which of the following disorders?

A. Social anxiety disorder.

B. Separation anxiety disorder.
C. Generalized anxiety disorder.
D. Selective mutism.

31
15.4 A 15-year-old girl has had school refusal for the last 7 months because she is
scared to leave her home, to be in crowded places or wide-open areas, and to ride
buses and trains with or without her parents. Which of the following diagnoses is
most consistent with this presentation?

A. Social anxiety disorder.

B. Separation anxiety disorder.
C. Generalized anxiety disorder.
D. Agoraphobia.

15.5 Which of the following psychotherapies has received the most evidence-based
support for treatment of a broad range of anxiety disorders in children and ado-
lescents?

A. Psychodynamic psychotherapy.
B. Exposure-based cognitive-behavioral therapy (CBT).
C. Parent-Child Interaction Therapy.
D. Family systems approach.

32 | Anxiety Disorders—Questions
 C H A P T E R 1 6

Posttraumatic Stress
Disorder and Persistent
Complex Bereavement
Disorder
16.1 According to DSM-5 criteria, exposure to a traumatic event by what means is con-
sidered insufficient for the diagnosis of posttraumatic stress disorder (PTSD) in
children 6 years and younger?

A. Directly experiencing the traumatic event.

B. Learning that a traumatic event occurred to a parent or caregiver.
C. Witnessing a traumatic event in electronic media, television, movies, or pic-
tures.
D. Witnessing a traumatic event occurring to a parent or caregiver.

16.2 How do children and adults differ in regard to DSM-5 Criterion B for posttraumatic
stress disorder (PTSD) (intrusive symptoms)?

A. Intrusive memories may not appear distressing in children and may be expressed
in play.
B. Distressing dreams in children very closely resemble the actual trauma.
C. Children may intrude on others by exhibiting extreme temper tantrums.
D. Children usually do not exhibit physiological reactions to trauma.

16.3 From whom should information typically be gathered when assessing children
for posttraumatic stress disorder (PTSD)?

A. The child.
B. The caretaker.
C. The child and caretaker.
D. The child’s teacher.

33
16.4 How is persistent complex bereavement disorder distinguished from normal grief
in children?

A. The grief is severe and persists for more than 6 months after the death.
B. The child fails to accept the permanence of the death.
C. The cause of the death was suicide or homicide.
D. The symptoms are consistent with cultural or religious norms.

16.5 When should medication be considered prior to psychotherapy in the treatment

of posttraumatic stress disorder (PTSD) in children?

A. When PTSD is the sole diagnosis without comorbidity.

B. When there are no safety concerns regarding the medications.
C. When the child is unable to function.
D. Medications should generally be considered as a first-line treatment for PTSD.

16.6 Which type of individual psychotherapy has the strongest evidence base for effec-
tively treating posttraumatic stress disorder (PTSD) in older children?

A. Trauma-focused cognitive-behavioral therapy (CBT).

B. Child–parent psychotherapy.
C. Narrative Exposure Therapy for Children (KidNET).
D. Trauma systems therapy.

16.7 When psychopharmacological treatment is indicated, which of the following med-

ications may be considered first line in the treatment of posttraumatic stress dis-
order (PTSD) in children?

A. Morphine.
B. Risperidone.
C. Prazosin.
D. Clonidine.

34 | PTSD and Persistent Complex Bereavement Disorder—Questions

 C H A P T E R 1 7

Obsessive-Compulsive
Disorder
17.1 Which of the following is true regarding epidemiological studies of obsessive-
compulsive disorder (OCD)?

A. More than 90% of cases of OCD have childhood onset.

B. OCD is characterized by two peaks of incidence, one occurring in adolescence
and another in early adulthood.
C. Prevalence of pediatric OCD is about 1%–2%, point prevalence 0.25%, and child-
hood onset occurs in about one-third to one-half of all cases.
D. Socioeconomic status and intelligence seem to not be associated with OCD in
youth.

17.2 What distinguishes pediatric obsessive-compulsive disorder (OCD) from adult

OCD?

A. Adult OCD has a higher familial rate than pediatric OCD.

B. Pediatric OCD has a better prognosis.
C. Cases of pediatric OCD do not seem to be etiologically related to pediatric au-
toimmune neuropsychiatric disorders associated with streptococcal infection
(PANDAS).
D. Pediatric OCD generally has a pubertal age of inset.

17.3 Which of the following is correct regarding pediatric obsessive-compulsive disor-

der (OCD) and comorbid disorders?

A. Earlier age at onset for OCD predicts increased risk for anxiety disorders but
not attention-deficit/hyperactivity disorder (ADHD).
B. In pediatric OCD, psychotic disorders are associated with older age and mood
disorders with younger age.
C. Comorbid Tourette’s disorder is associated with an earlier age at onset and lower
chronological age.
D. In contrast to Tourette’s disorder alone, OCD with comorbid Tourette’s usually
does not show a remission of tics during adolescence.

35
17.4 What are key features of the frontostriatal model of obsessive-compulsive disor-
der (OCD)?

A. It is based on a hypothesis of decreased glutamate.

B. Major brain structures central to OCD include the orbitofrontal cortex, ante-
rior cingulate cortex, caudate, and thalamus.
C. In contrast to adults, pediatric OCD imaging studies detect structural abnor-
malities in the cingulate cortex, basal ganglia, and thalami.
D. Functional imaging studies prior to and following treatment have shown
greater results in children with OCD than in adults with OCD.

17.5 Which of the following is true about genetic and environmental factors in obses-
sive-compulsive disorder (OCD)?

A. According to twin studies, genetic factors are more important than unique en-
vironmental factors.
B. According to a sample study of female twin pairs, heritability was higher for
compulsions than obsessions.
C. Many to most cases of OCD arise without a positive family history of the dis-
order.
D. There does not seem to be a correlation between “normative” ritualistic behav-
iors in childhood and the subsequent onset of OCD.

17.6 How much of the reduction in Children’s Yale-Brown Obsessive Compulsive

Scale (CY-BOCS) scores is thought to be clinically significant?

A. 50%–70% reduction.
B. 25%– 40% reduction.
C. Anything greater than a 5% reduction.
D. Anything greater than a 50% reduction.

17.7 For diagnostic criteria for pediatric autoimmune neuropsychiatric disorders asso-
ciated with streptococcal infection (PANDAS) to be met, when does onset have to
occur?

A. Between ages 3 and 10 years.

B. Between ages 3 and 12 years, or Tanner I or II.
C. Before age 18 years.
D. Between ages 3 and 15 years, or Tanner I through IV.

17.8 How can symptoms of obsessive-compulsive disorder (OCD) be differentiated

from those of other disorders, such as autism spectrum disorder and psychotic
disorders?

A. Children with autism spectrum disorder often display discomfort when per-
forming repetitive activities, whereas those with OCD usually do not have dis-
cernible anxiety.

36 | Obsessive-Compulsive Disorder—Questions
B. In children with OCD, insight usually varies with level of anxiety, whereas in
children with delusional thought, symptoms are often static.
C. The nature of obsessional ideation is less often odd and atypical in pediatric
patients with psychosis than in those with OCD.
D. Symptoms of autism spectrum disorder may be easily confused with OCD, es-
pecially in young children, and about 15% of children with OCD may also
meet criteria for autism spectrum disorder.

Obsessive-Compulsive Disorder—Questions | 37
 C H A P T E R 1 8

Early Onset Schizophrenia

18.1 How does early onset schizophrenia (EOS) compare with adult-onset schizophrenia?

A. EOS is not associated with intellectual deficits.

B. EOS is associated with more genetic mutations, such as copy number variations.
C. Medical conditions are not part of the differential diagnosis for EOS.
D. EOS is not associated with chronic impairment.

18.2 What neuroanatomical abnormality is most common in early onset and adult-
onset schizophrenia?

A. Increased brain connectivity.

B. Loss of gray matter.
C. White matter enhancement.
D. Increased total brain volumes.

18.3 What is a common occurrence in both youth and adults with schizophrenia?

A. The differential diagnosis is limited.

B. An individual must have continuous signs of disturbance for at least 1 year for
the diagnosis.
C. Patients progress through four phases: prodromal, acute, recovery, and residual.
D. Neuroanatomical abnormalities are rare.

18.4 Which of the following symptoms of psychosis are most specifically associated
with early onset schizophrenia (EOS)?

A. Negative symptoms.
B. Catatonic symptoms.
C. Complex delusions.
D. Hallucinations and disordered thinking.

39
18.5 Which of the following is true about early onset schizophrenia (EOS)?

A. Typically, only those children with schizophrenia experience hallucinations.

B. EOS typically occurs around the same time as autism spectrum disorder (ASD).
C. Family, twin, and adoption studies reveal a weak genetic component for
schizophrenia.
D. Longer duration of untreated psychosis and greater severity of negative symp-
toms at the time of diagnosis predict greater functional impairment over time.

40 | Early Onset Schizophrenia—Questions

 C H A P T E R 1 9

Psychiatric Aspects of
Chronic Physical Disorders
19.1 Which of the following is important for parents helping a child to adjust to his or
her illness?

A. Continuation of “family rules” and appropriate limit setting.

B. Relinquishing control to the child.
C. Giving the child excessive attention and reassurance.
D. Frequently apologizing to the child.

19.2 Renal disease affects the metabolism of which of the following medications?

A. Diazepam.
B. Duloxetine.
C. Trazodone.
D. Venlafaxine.

19.3 Clonidine can have which of the following cardiac effects?

A. Increase in systolic blood pressure.

B. Decrease in systolic blood pressure.
C. Increase in heart rate.
D. Increase in cardiac output.

19.4 Which of the following is an approach-oriented coping style?

A. A coping method that directly handles the stressor and the subsequent emo-
tional response.
B. A coping style that seeks to control upset by evading the stressor.
C. A practical approach that focuses primarily on the problems at hand.
D. A coping style that focuses on regulating emotional responses.

41
19.5 Which of the following is true regarding treatment adherence in physically ill
children?

A. Illnesses that require long periods of follow-up are associated with higher lev-
els of treatment adherence.
B. Compared with chronic illnesses, acute conditions have higher rates of treat-
ment nonadherence.
C. Family therapy is not indicated for treatment adherence problems.
D. Children are at greater risk for treatment noncompliance when they have a his-
tory of psychological distress.

42 | Psychiatric Aspects of Chronic Physical Disorders—Questions

 C H A P T E R 2 0

Eating and Feeding

Disorders
20.1 Which comorbid psychiatric disorder or class of disorders has the highest lifetime
prevalence in adults with anorexia nervosa according to research data?

A. Substance use disorders.

B. Posttraumatic stress disorder.
C. Anxiety disorders.
D. Mood disorders.

20.2 The Body Project has focused on which of the following risk factors for eating dis-
order behavior and demonstrated reliable long-term reduction?

A. Teasing by peers.
B. Maternal preoccupation with dietary restriction.
C. Body dissatisfaction.
D. Internalizing the thin-ideal of the fashion industry.

20.3 Which of the following medical sequelae of anorexia nervosa may persist after
weight restoration?

A. Bradycardia.
B. Osteopenia.
C. Hypothermia.
D. Dehydration.

20.4 For which variable did a comparative trial demonstrate that patients in behavior-
al systems family therapy showed greater improvement at the end of treatment
than patients in ego-oriented individual therapy?

A. Eating attitudes.
B. Weight gain.
C. Depression.
D. Self-reported eating-related family conflict.

43
20.5 An open-label medication trial including adolescents supports the use of fluoxe-
tine for treatment of which eating or feeding disorder?

A. Pica.
B. Anorexia nervosa.
C. Bulimia nervosa.
D. Rumination.

44 | Eating and Feeding Disorders—Questions

 C H A P T E R 2 1

Tic Disorders
21.1 What are the most current recommendations regarding the pharmacological
treatment of attention-deficit/hyperactivity disorder (ADHD) in the context of
co-occurring Tourette’s disorder or chronic tics?

A. Longitudinal studies have found that methylphenidate or dextroamphetamine

treatment may cause significant increases in tics.
B. Stimulants are currently the first-line agents for ADHD and comorbid Tourette’s.
C. In one study, worsening of tics in Tourette’s occurred in about one-third of all pa-
tients, and occurred less in patients given placebo than in those given stimulants.
D. Atomoxetine is not recommended in patients with tics because of a lack of
data.

21.2 Which of the following is true regarding tics?

A. Tics can mimic others’ movements (echopraxia) or words (echolalia) or sounds

in the environment.
B. The ability to postpone tics is relatively static throughout the day and across
situations.
C. Tics are not typically influenced by suggestion.
D. It is common for tics to follow a physical or emotional stimulus and then stop
soon after the stimulus has ended.

21.3 Which of the following is true regarding the incidence and course of tic disorders?

A. Tics typically have onset in middle to late adolescence.

B. Most adults who continue to have tics have mild symptoms.
C. The peak incidence of tics is during ages 7–10 years.
D. Less than half of individuals with tics find relief of symptoms in late adoles-
cence and early adulthood.

21.4 What has been theorized regarding the etiology of tics in various brain regions and
at the cellular level?

A. Norepinephrine and serotonin in medium-size spiny neurons (MSPNs) in the

striatum play a key role in producing tics.

45
 B. Hyperactivation of the basal ganglia and hypoactivation of sensorimotor re-
gions occur in individuals with Tourette’s.
C. Tic movements may result from an imbalance in the relationship between sen-
sorimotor regions and the basal ganglia.
D. When neuronal migration of interneurons acting on MSPNs is impaired during
early childhood, an imbalance occurs in their density and number, leading to
tics.

21.5 Which of the following is false regarding habit reversal training?

A. Tics with premonitory urges are more difficult to treat with habit reversal
training than are tics without these urges.
B. Habit reversal training can be more successful than wait list conditions or sup-
portive therapy.
C. Rhythmic breathing is often used in habit reversal training for vocal tics.
D. The number of children treated with habit reversal training remains small.

21.6 According to DSM-5 criteria, which statement is correct in regard to diagnosing

Tourette’s disorder, persistent (chronic) motor or vocal tic disorder, or provisional
tic disorder?

A. For provisional tic disorder to be diagnosed, the tics must have been present
for less than 6 months since first tic onset.
B. For persistent (chronic) motor or vocal tic disorder to be diagnosed, both mul-
tiple motor and one or more vocal tics have been present at some time during
the illness, although not necessarily concurrently.
C. For Tourette’s disorder to be diagnosed, single or multiple motor or vocal tics
have been present during the illness, but not both motor and vocal.
D. For persistent (chronic) motor or vocal tic disorder to be diagnosed, single or
multiple motor or vocal tics have been present during the illness, but not both
motor and vocal.

21.7 How does the prevalence of Tourette’s differ between boys and girls?

A. The prevalence of Tourette’s in boys is four times that of girls.

B. The prevalence of Tourette’s in boys is double that of girls.
C. For chronic motor tics and transient tics, the prevalence in boys is four times
that of girls.
D. For chronic motor tics and transient tics, the prevalence in boys is double that
of girls.

46 | Tic Disorders—Questions
 C H A P T E R 2 2

Elimination Disorders
22.1 Which of the following is true regarding the course and prognosis of enuresis?

A. Enuresis typically persists through adolescence.

B. Enuresis is typically a self-limited disorder with a relatively high rate of spon-
taneous remission.
C. Enuresis requires either pharmacological or behavioral intervention to remit.
D. Enuresis typically remits by age 5.

22.2 In a child with enuresis, what is the primary concern with regard to medical co-
morbidity?

A. Sleep apnea.
B. Seizure disorder.
C. Urinary tract infection.
D. Diabetes mellitus.

22.3 What treatment is recommended for a child with refractory primary enuresis?

A. Imipramine.
B. Psychotherapy.
C. Retention-control training.
D. Reward systems.

22.4 The mother of a 6-year-old boy accuses her ex-husband of sexually abusing the
child, who has new-onset voluntary encopresis and hoarding of feces. Which of
the following is an appropriate action for the psychiatrist?

A. Refer the child to a pediatrician to investigate for sexual abuse, because volun-
tary encopresis and hoarding of feces is always diagnostic for sexual abuse.
B. Do not request any medical evaluation because this encopresis is a purely psy-
chological symptom.
C. Question the mother more carefully because encopresis rarely occurs in boys.
D. Refer the child for a medical evaluation to rule out thyroid disease.

47
22.5 What is the correct diagnostic terminology for a 7-year-old child who has never
achieved fecal continence and has a history of chronic constipation?

A. Secondary retentive encopresis.

B. Primary retentive encopresis.
C. Secondary nonretentive encopresis.
D. Primary nonretentive encopresis.

48 | Elimination Disorders—Questions
 C H A P T E R 2 3

Sleep Disorders
23.1 What is the first and most important step in assessing children and adolescents for
sleep disorders?

A. A sleep log/sleep diary.

B. A sleep history.
C. Actigraphy.
D. Nocturnal polysomnography.

23.2 What is the first line of treatment for childhood insomnia disorders?

A. Nonpharmacological interventions.
B. Sedative-hypnotics.
C. Allowing the child to go to sleep whenever he or she wishes.
D. Other pharmacological agents.

23.3 What is always required in an accurate DSM-5 diagnosis of narcolepsy?

A. Hypocretin deficiency in the absence of acute brain injury, inflammation, or

infection.
B. Recurrent periods of an irrepressible need to sleep, lapsing into sleep, or nap-
ping recurring within the same day, which must have occurred at least three
times per week over the past 3 months.
C. Nocturnal sleep polysomnography showing rapid eye movement (REM) sleep
latency less than or equal to 15 minutes, or a multiple sleep latency test show-
ing a mean sleep latency less than or equal to 8 minutes and two or more sleep-
onset REM periods.
D. Episodes of cataplexy occurring at least a few times per month.

23.4. How does narcolepsy commonly present in children?

A. Daytime sleepiness, cataplexy, hypnagogic hallucinations, and sleep paralysis.

B. Excessive daytime sleepiness and sleep attacks.
C. Daytime sleepiness, cataplexy, and hypnagogic hallucinations.

49
 D. Excessive daytime sleepiness and sleep attacks, often masked by behavioral
and emotional symptoms such as irritability, hyperactivity, inattention, and
increased sleep needs at younger age.

23.5 What is the prevalence of restless legs syndrome in the pediatric population?

A. 0.5%.
B. 1%.
C. 2%.
D. 5%.

23.6 What is the treatment of choice for pediatric obstructive sleep apnea (OSA)?

A. Inhaled nasal steroids, antihistamines, and decongestants.

B. Supplemental oxygen.
C. Continuous positive airway pressure (CPAP).
D. Surgery.

23.7 Which of the following parasomnias might occur during rapid eye movement
(REM) sleep?

A. Night terrors.
B. Confusional arousals.
C. Nightmares.
D. Sleepwalking.

23.8 Which of the following is among the essential parts of treatment for delayed sleep
phase syndrome?

A. Melatonin.
B. Sleep hygiene, family and child education, and the gradual advancement of
sleep phase.
C. Blue light therapy.
D. Bright light therapy.

23.9 What are some of the most prevalent sleep-related symptoms among children and
adolescents with depressive disorders?

A. Problems with sleep initiation, sleep maintenance, and hypersomnia.

B. Snoring.
C. Parasomnias such as sleepwalking, night terrors, confusional arousals, and
rapid eye movement (REM) behavior sleep disorder.
D. Longer sleep-onset latency and less total sleep with reduced sleep efficiency.

50 | Sleep Disorders—Questions
 C H A P T E R 2 4

Evidence-Based Practice
24.1 Which of the following characterizes the process of evidence-based practice?

A. Decisions about health care are based on conventions of practice.

B. Decisions should be made by those providing care.
C. Decisions should be informed by the tacit and explicit knowledge of those pro-
viding care.
D. Decisions should be made independently of the context of available resources.

24.2 According to Leape and colleagues (1991), the use of solely supportive treatment
for an abuse victim would be best classified as what type of medical practice error?

A. Performance error.
B. Prevention error.
C. Diagnosis error.
D. Systemic functioning error.

24.3 Which of the following is a characteristic of the evidence-based treatment model

and its role in communicating from the body of scientific knowledge to the actors
in the therapeutic change process?

A. The model has emphasized the packing of scientific knowledge into specific
protocols that are disseminated to the field and then tested.
B. The model has emphasized the establishment of social processes to use the ex-
pertise of knowledgeable individuals in plans of care that may be implemented
and monitored.
C. The model emphasizes the integration of evidence at the time of protocol de-
sign and delivers that knowledge to the process of care through the nature and
order of the procedures in the protocol, with controls emphasizing integrity to
the treatment model.
D. The model delivers knowledge to the process of care through individual recall
and social communication with controls that emphasize accountability to at-
tain patient goals.

51
24.4 Which of the following is a factor suggested by studies of implementation to be
critical for success of a health system?

A. Avoidance of risk taking.

B. Unavailability of “extra” resources.
C. Accessible staff training and coaching.
D. A culture that encourages proprietorship of knowledge.

24.5 Which of the following reflects attitudes regarding structured approaches to in-
terviewing and diagnosis?

A. Patients tend to prefer unstructured approaches.

B. Patients perceive structured and unstructured approaches to be equally com-
prehensive.
C. Patients perceive structured approaches as damaging of rapport.
D. Clinicians’ beliefs of patients’ perceptions regarding structured approaches gen-
erally do not reflect patients’ actual perceptions.

24.6 Which of the following is a common error that occurs in the evaluation process,
in treatment planning, and in tracking outcomes?

A. Overinclusion of comorbid disorders in the course of evaluation.

B. Reluctance to assign “no disorder” in the course of evaluation.
C. Failure to dismiss existing evidence as irrelevant or infeasible.
D. Overreliance on a validated instrument to track a targeted domain.

52 | Evidence-Based Practice—Questions
 C H A P T E R 2 5

Child Abuse and Neglect

25.1 Treatment of an abused child should focus on which of the following goals?

A. Protecting the child.

B. Reducing familial cohesion.
C. Telling the child the abuse is his or her fault.
D. Avoiding issues of betrayal.

25.2 What kind of sexual activity generally involves mutually interested children at
similar ages and developmental stages and does not involve coercion?

A. Sexual abuse.
B. Sexual play.
C. Sexual contact that also involves an adult.
D. Sexual contact that also involves a parent.

25.3 Which of the following is indicative of whiplash shaken baby syndrome?

A. Repeated urinary tract infections and/or hematuria.

B. Retinal hemorrhages.
C. Vague somatic complaints such as abdominal pain and headaches.
D. External cranial trauma.

25.4 Which of the following neuroanatomical findings is most associated with posttrau-
matic stress disorder?

A. Increased hippocampal size.

B. Normal limbic activity.
C. Decreased hippocampal size.
D. No change in hippocampal size.

25.5 What is the first step in the treatment of children who are victims of abuse?

A. Educate parents about appropriate forms of child discipline.

B. Make certain that the child is protected and safe from further injury and abuse.
C. Promote social awareness through media campaigns and public education.
D. Identify whether the child belongs to a high-risk group.

53
 C H A P T E R 2 6

Cultural and Religious Issues

26.1 Which of the following statements defines cultural psychiatry?

A. The discipline concerned with an individual’s identity with a group of people

sharing common origins, history, customs, and beliefs as it affects description,
assessment, diagnosis, biopsychosocial formulation, treatment planning, and
training in all aspects of psychiatric practice.
B. The discipline concerned with matters of culture, ethnicity, and race as they af-
fect description, assessment, diagnosis, biopsychosocial formulation, treat-
ment planning, and training in all aspects of psychiatric practice.
C. The discipline concerned with physical, biological, and genetic qualities of
humans, as they affect description, assessment, diagnosis, biopsychosocial for-
mulation, treatment planning, and training in all aspects of psychiatric practice.
D. The discipline concerned with the set of values, behavioral norms, and mean-
ing used by members of a particular society to construct their unique view of
the world as they affect description, assessment, diagnosis, biopsychosocial
formulation, treatment planning, and training in all aspects of psychiatric
practice.

26.2 What are cultural syndromes?

A. A way of conceptualizing and communicating about suffering experienced by

individuals within a cultural group.
B. A set of consistent and specific symptoms occurring in cultural groups or
contexts.
C. The reason or reasons for symptoms or distress within a cultural group.
D. The cultural features of the relationship between the individual and the clinician.

26.3 Which are the foundational units in which children are conceived, grow, and de-
velop in virtually every culture?

A. Marriage and family.

B. Family and ethnicity.
C. Marriage and race.
D. Family and religion.

55
26.4 Which of the following is a characteristic of culturally competent child and ado-
lescent mental health clinicians?

A. Disregard the cultural biases they bring to their work.

B. Appreciate cultural influences on development, distress, and symptom ex-
pression.
C. Exclude cultural strengths in assessment and treatment.
D. Do not ask about individual and group trauma associated with immigration.

26.5 Which of the following best describes some of the concepts of fundamentalism?

A. Religion and faith communities that are not restricted to organized religion
and group membership.
B. Organized system of beliefs, principles, rituals, practices, and related symbols
that brings individuals and groups to sacred or ultimate reality and truth.
C. Philosophy of life or belief system that addresses life’s most common, basic
questions.
D. Strict interpretation of sacred writings, traditional lifestyle practices guided by
religious teachings, and suspicion of or resistance to modernity.

56 | Cultural and Religious Issues—Questions

 C H A P T E R 2 7

Youth Suicide
27.1 A 17-year-old girl has a 3-year history of major depressive disorder and intermit-
tent suicidal thoughts. She discloses that she has new intermittent thoughts of
cutting, and made one very superficial cut with her razor a week ago, following
a fight she had with her boyfriend. She denies current acute suicidal ideation.
What is the most important next step in your clinical management?

A. Ask her to sign a safety contract for times she has suicidal urges.
B. Discuss starting medication to reduce suicide risk.
C. Take her to the emergency room for possible inpatient hospitalization.
D. Discuss a plan for safety with her and her parents, including how to ensure her
safety.

27.2 What is the most accurate statement regarding psychopathology in youth who
die by suicide?

A. A significant proportion of youth suicide attempters have no clear evidence of

psychopathology.
B. Persistent negative affect (neuroticism) is one of the strongest risk factors.
C. A strong desire for perfectionism is closely associated with completed suicides.
D. Family history of bipolar and major depressive disorders, even without a his-
tory of completed suicides, places youth at higher risk for completed suicide.

27.3 What would be the most helpful short- and long-term psychopharmacological
and psychotherapeutic approach to treatment that would decrease suicidal ide-
ation according to the research?

A. A combined approach, utilizing both a selective serotonin reuptake inhibitor

(SSRI) and cognitive-behavioral therapy (CBT).
B. A combined approach, utilizing SSRI, CBT, and family psychoeducation.
C. An approach utilizing multisystemic therapy, a family-based treatment.
D. Consideration of family therapy and either CBT or dialectical behavior ther-
apy, and cautious use of SSRIs, due to increased risk of suicidal ideation.

57
27.4 You evaluate a 17-year-old boy with bipolar disorder in the emergency depart-
ment because of his psychiatrist’s concern about his expressing acute suicidal
thoughts. This is the boy’s fourth visit to the emergency room in 4 weeks. What is
the most effective way to assess his suicidality?

A. Begin by asking mostly general questions about his mood, to establish rap-
port, rather than asking details about intent or preparatory behavior.
B. Elicit a social history, especially addressing any recent interpersonal challenges
with loved ones.
C. Understand more specific details about the severity of his suicidal ideation, with
less focus on the pervasiveness.
D. Clarify his relatively low intent, implying a lesser likelihood of lethality.

27.5 Which of the following is the most accurate statement regarding suicide attempt
or completion?

A. Hispanic youth have a higher rate of suicides than American Indian youth.
B. Suicide is the third leading cause of death in youth.
C. The lifetime prevalence of suicide attempts in youth is 2.4%.
D. Rates of completed suicides in youth demonstrate a male:female ratio of 3:1.

58 | Youth Suicide—Questions
 C H A P T E R 2 8

Gender Dysphoria and

Nonconformity
28.1 What term or concept refers to the sex of a person to whom an individual is erot-
ically attracted?

A. Natal sex.
B. Gender identity.
C. Gender expression.
D. Sexual orientation.

28.2 According to cognitive theories of gender development, the majority of children

have a sense of gender identity by what age?

A. 1 year.
B. 3 years.
C. 8 years.
D. 12 years.

28.3 Which group is most often referred for treatment in the context of gender variance?

A. Child natal boys.

B. Child natal girls.
C. Adolescent natal boys.
D. Adolescent natal girls.

28.4 Regarding the two factors—cognitive gender confusion and affective gender con-
fusion—measured by the Gender Identity Interview for Children (GIIC), what
was identified as the strongest predictor of persistence of gender dysphoria from
childhood into adolescence?

A. Lower cognitive gender confusion.

B. Higher cognitive gender confusion.
C. Lower affective gender confusion.
D. Higher affective gender confusion.

59
28.5 Based on prospective research, which of the following is true regarding the trajec-
tory of the majority of those who experience childhood gender dysphoria?

A. Gender dysphoria persists during early adolescence.

B. Gender dysphoria “desists” in adulthood.
C. As adults, these individuals are more likely to express a gender identity incon-
sistent with their natal sex.
D. As adults, these individuals more often identify as gay, lesbian, or bisexual
than as heterosexual.

60 | Gender Dysphoria and Nonconformity—Questions

 C H A P T E R 2 9

Aggression and Violence

29.1 What is typically meant by the term predatory aggression?

A. Attempting to cause pain to the victim with no independent gain.

B. Goal-directed behavior that offers some benefit to the aggressor.
C. Deliberate, controlled aggression.
D. Impetuous, poorly controlled aggression.

29.2 Prosocial aggression (e.g., male dominance) appears to be heavily influenced by

_______________, while impulsive aggression is more consistently related to
_____________.

A. Serotonin (5-HT), testosterone.

B. Norepinephrine, 5-HT.
C. Testosterone, norepinephrine.
D. Testosterone, 5-HT.

29.3 Cerebrospinal fluid levels of what metabolite have been inversely correlated with
measures of aggressive behavior in both male and female primates?

A. 5-Hydroxyindoleacetic acid (5-HIAA).

B. Norepinephrine.
C. Serotonin (5-HT).
D. Dopamine.

29.4 What is the candidate gene that codes for a transporter receptor that is most con-
sistently linked to aggression?

A. Dopamine transporter.
B. Norepinephrine transporter.
C. Serotonin (5-HT) transporter.
D. Testosterone transporter.

61
29.5 Findings suggest that what type of violence exposure is the most robust predictor
of externalizing problems?

A. Witnessing violence against familiars.

B. Being directly exposed to violence.
C. Hearing reports of aggression toward familiars.
D. Hearing reports of aggression toward strangers.

29.6 What is the best-studied and best-validated treatment for youth aggression?

A. Cognitive-behavioral therapy.
B. Multidimensional Treatment Foster Care.
C. Behavioral parent training.
D. Multisystemic treatment.

62 | Aggression and Violence—Questions

 C H A P T E R 3 0

Psychiatric Emergencies
30.1 Research consistently finds which of the following two are among the most salient
risk factors for future suicide attempts?

A. Substance abuse and recent loss.

B. Suicidal ideation and poor social supports.
C. Being a victim of physical or sexual abuse and having poor impulse control.
D. Suicidal ideation and history of suicide attempts.

30.2 Which of the following is a concise screening instrument that can be used to screen
for substance use in the emergency department (ED) setting?

A. Children’s Depression Inventory (CDI).

B. CRAFFT.
C. Patient Health Questionnaire–9 (PHQ-9).
D. Screen for Child Anxiety Related Emotional Disorders (SCARED).

30.3 What is the most commonly recommended medication for patients with delirium
in the pediatric emergency department?

A. Risperidone.
B. Olanzapine.
C. Quetiapine.
D. Lorazepam.

30.4 Which medication class has demonstrated efficacy in the treatment of aggression
and self-injurious behavior in intellectually and developmentally delayed patients
as well as the treatment of adolescent aggression across psychiatric diagnoses?

A. Typical antipsychotics.
B. Atypical antipsychotics.
C. Benzodiazepines.
D. Antihistamines.

63
30.5 Which of the following interventions is agreed on by most experts as the first inter-
vention when managing aggression?

A. Behavioral approaches.
B. Seclusion.
C. Restraint.
D. Pharmacological interventions.

64 | Psychiatric Emergencies—Questions
 C H A P T E R 3 1

Family Transitions
Challenges and Resilience
31.1 To foster immediate and long-term adaptation for children after the death of a
family member, what should the psychiatrist recommend to the family?

A. Share acknowledgment of the reality of death and loss through information

and communication.
B. Stop memorial rituals.
C. Continue the same relationships and role functions among family members.
D. Focus on maintaining bonds with the deceased as a living presence.

31.2 What could an adoptive parent do to help an adopted child benefit developmentally?

A. Deny contact with the birth family.

B. Acclimate the child only to the culture of the adoptive parent.
C. Participate in an open adoption.
D. Establish that the adoptive parent is not the “natural” parent.

31.3 A 12-year-old girl is the daughter of immigrants from Thailand. The family lives
in a middle-class community with her aunts, uncles, and cousins. Her parents
have college educations and both are working; her father has needed to change
jobs three times in the last year. What factor is the most challenging to their resil-
ience in the setting of immigration?

A. Father’s recurring job transitions.

B. Availability of family.
C. Parents’ education level.
D. Having both parents work.

31.4 Which family transition is considered the most manageable?

A. Loss of a parent’s job.

B. Adoption of a child.
C. Divorce.
D. Parental illness.

65
31.5 Jim was divorced and then married Betty. They have two children together (10
years old and 5 years old), and Jim’s daughter (14 years old) from his previous
marriage lives with them. Betty and her stepdaughter have a tumultuous rela-
tionship. Jim and Betty recently have had a miscarriage. What factor does not con-
tribute to their risk of divorce?

A. Jim’s previous divorce.

B. Their miscarriage.
C. This being Betty’s first marriage.
D. The relationship between Betty and her stepdaughter.

31.6 Which of these situations is an ambiguous loss?

A. Miscarriage.
B. Homicide.
C. Dementia.
D. Lingering death.

31.7 Which scenario involves the clinician using a resilience-oriented approach?

A. Encouraging a parent and child to reach a hierarchical understanding.

B. Focusing on negative influences of substance abuse.
C. Facilitating the creation of a bicultural identity in the setting of migration.
D. Promoting passive acceptance in the setting of transitions.

31.8 A child is removed from the home to protect him from abuse. Which intervention
is consistent with a collaborative resilience-oriented approach?

A. Reinforce that the decisions are out of the family’s control.

B. Mobilize the kin network to provide input on a safe option.
C. Reinforce separation of foster and kin networks.
D. Discontinue sessions after the child returns to his parent.

66 | Family Transitions—Questions
 C H A P T E R 3 2

Legal and Ethical Issues

32.1 In which landmark case did the court decision state, “So long as the child is part
of a viable family his own interests are merged with those of the other members”?

A. Santosky v. Kramer (455 U.S. 745 [1982]).

B. Tarasoff v. Regents of the University of California (551 P.2d 334 [1976]).
C. Finlay v. Finlay (148 N.E. 624 [N.Y. ct. app. 1925]).
D. Dusky v. United States (362 U.S. 402 [1960]).

32.2 Which ethical principle relates to the allocation of resources and fair and equitable
distribution of risks and benefits?

A. Beneficence.
B. Justice.
C. Equipoise.
D. Autonomy.

32.3 Which best describes the duty of confidentiality?

A. The patient’s right to prevent disclosure of information obtained during treat-

ment in judicial or quasi-judicial proceedings.
B. The clinician’s obligation to obtain consent from a minor before reporting child
neglect.
C. The clinician’s obligation to avoid disclosure of the patient’s information to any
person other than the patient.
D. The emancipated patient’s right to give consent for his or her own treatment.

32.4 Which standard governs the termination of parental rights?

A. Clear and convincing evidence.

B. Beyond a reasonable doubt.
C. Reasonable degree of medical certainty.
D. Preponderance of the evidence.

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 C H A P T E R 3 3

Telemental Health
33.1 Which of the following statements is true regarding telemental health (TMH)?

A. TMH is part of mental health services that use secure, real-time, interactive, two-
way videoconferencing technology.
B. TMH involves any services that utilize low-grade technology to improve com-
munication with patients.
C. TMH is used only by primary care physicians to consult with mental health
providers.
D. TMH allows patients and families to post mental health questions online to be
answered over a period of days to weeks.

33.2 How does telemental health (TMH) address possible challenges in providing
mental health services to adolescents in underserved areas?

A. TMH focuses on the significant difference in diagnoses evaluated through vid-

eoconferencing (VC) and in usual outpatient practices.
B. TMH allows patients to be evaluated in their own communities.
C. TMH systems provide all infrastructures needed to implement VC services.
D. TMH arranges transportation to distant health centers that provide mental
health treatment.

33.3 Which of the following statements is true about research supporting the effective-
ness of telemental health (TMH) for adolescents?

A. The body of literature supporting child and adolescent TMH is equal to the adult
literature.
B. No studies have been done to support the effectiveness of TMH in children and
adolescents.
C. All the studies have been randomized, double-blind trials.
D. The majority of reports of TMH with children and adolescents are descriptive
and address feasibility of TMH in increasing access to service.

69
33.4 Which of the following is a true statement about a virtual clinical encounter?

A. A high-quality video signal is crucial to the success of a virtual encounter.

B. Confidentiality is not a key concern during a virtual encounter.
C. Only the child or adolescent and his or her family should be present during an
encounter.
D. The size of the room at the patient site does not matter.

33.5 How does virtual clinical care provided via telemental health (TMH) compare to
traditional encounters?

A. There is no need to modify psychiatric assessment during a virtual encounter.

B. Clinical care provided by TMH should be consistent with other professional
parameters.
C. Models of care are the same whether medication is prescribed directly by a te-
lepsychiatrist or by a referring primary care physician.
D. Additional direction and contact between sessions are not necessary for virtual
encounters.

33.6 Which of the following accurately describes a regulatory issue affecting telemen-
tal health (TMH) services?

A. A telemedicine license eliminates the need for additional licenses to practice

in different states.
B. Virtual encounters are not regulated by Health Insurance Portability and Ac-
countability Act (HIPAA) guidelines.
C. Malpractice insurance needs to cover the telemedicine practice.
D. It is a security violation to collect identifying information about the patient.

70 | Telemental Health—Questions
 C H A P T E R 3 4

Principles of
Psychopharmacology
34.1 What is the general role of parental consent in determining whether a patient
younger than age 18 can undergo a psychiatric assessment?

A. The parents always need to consent to the evaluation.

B. The parents do not need to consent to the evaluation.
C. The parents generally need to consent to the evaluation, although some states
allow underage consent in certain situations.
D. The parents do not need to consent to the evaluation, except in emergency sit-
uations.

34.2 When initiation of a psychotropic medication is being considered for a pediatric

patient, within what time frame should the patient ideally have had a physical ex-
amination by his or her primary medical doctor?

A. Within the past 3 months.

B. Within the past 6 months.
C. Within the past 1 year.
D. Within the past 2 years.

34.3 In regard to pharmacokinetics, how do hepatic drug metabolism, renal excretion,

and plasma concentrations of hydrophilic drugs differ between children and
adults?

A. Children may have more rapid elimination of drugs that use hepatic pathways,
more rapid excretion of drugs that use renal pathways, and lower plasma con-
centrations of hydrophilic drugs.
B. Children have less rapid elimination of drugs that use hepatic pathways, less
rapid elimination of drugs that use renal pathways, and higher plasma concen-
trations of hydrophilic drugs.
C. Children have more rapid elimination of drugs that use hepatic pathways, less
rapid elimination of drugs that use renal pathways, and lower plasma concen-
trations of hydrophilic drugs.

71
 D. Children have less rapid elimination of drugs that use hepatic pathways, more
rapid elimination of drugs that use renal pathways, and higher plasma concen-
trations of hydrophilic drugs.

34.4 At approximately what age do a child’s pharmacokinetic characteristics begin to

become more like those of an adult?

A. Age 13 years.
B. Age 15 years.
C. Age 18 years.
D. Age 21 years.

34.5 Which federal regulatory act first gave pharmaceutical companies greater finan-
cial incentives to voluntarily conduct clinical trials of medications in children and
adolescents?

A. Pediatric Research Equity Act (PREA).

B. Best Pharmaceuticals for Children Act (BPCA).
C. Food and Drug Administration Safety and Innovation Act (FDASIA).
D. Food and Drug Administration Modernization Act (FDAMA).

72 | Principles of Psychopharmacology—Questions
 C H A P T E R 3 5

Medications Used for

Attention-Deficit/
Hyperactivity Disorder
35.1 When treating attention-deficit/hyperactivity disorder (ADHD), what age group
appears to respond less well to stimulant therapy and may be more treatment re-
fractory?

A. Preschoolers.
B. Latency-age children.
C. Adolescents.
D. Adults.

35.2 What is one of the two most commonly reported side effects of stimulant medication?

A. Appetite increase.
B. Sleep disturbances.
C. Mood disturbances.
D. Lethargy.

35.3 Which long-acting stimulant is a prodrug, which is converted in the body to the
active medication after enzymatic hydrolysis?

A. Concerta (methylphenidate).
B. Metadate CD (controlled-delivery methylphenidate).
C. Adderall XR (extended-release mixed salts of levoamphetamine and dextro-
amphetamine).
D. Vyvanse (lisdexamfetamine dimesylate).

35.4 What is a potential serious side effect of atomoxetine?

A. Decrease in diastolic blood pressure.

B. Abnormal electrocardiographic (ECG) intervals.

73
 C. High abuse potential.
D. Severe liver injury.

35.5 Which of the following nonstimulant medications has U.S. Food and Drug Ad-
ministration (FDA) approval for the treatment of attention-deficit/hyperactivity
disorder (ADHD)?

A. Immediate-release clonidine.
B. Extended-release guanfacine.
C. Bupropion.
D. Tricyclic antidepressants.

35.6 Which of the following is true regarding nonstimulant pharmacotherapy for atten-
tion-deficit/hyperactivity disorder (ADHD)?

A. Guanfacine extended release (GXR) should not be used adjunctively with

stimulants.
B. Bupropion has an indirect mixed antagonist effect on dopamine and norepi-
nephrine.
C. Selective serotonin reuptake inhibitors (SSRIs) are useful in treating symp-
toms of ADHD.
D. Modafinil has the potential side effect of causing serious Stevens-Johnson–like
rashes.

74 | Medications Used for ADHD—Questions

 C H A P T E R 3 6

Antidepressants
36.1 Increased rates of suicidality reported in children and adolescents treated with
antidepressants relative to placebo appear to extend to what age?

A. Age 18 years.
B. Age 21 years.
C. Age 24 years.
D. Age 28 years.

36.2 A 16-year-old boy with recurrent major depressive disorder and a seizure disor-
der has not responded to treatment with an adequate trial of fluoxetine. His de-
pression did not improve with a prior adequate trial of escitalopram. Which of the
following would be the next appropriate psychopharmacological treatment?

A. Tranylcypromine.
B. Nortriptyline.
C. Venlafaxine.
D. Bupropion.

36.3 A 6-year-old girl presents with obsessions of contamination and compulsive

handwashing to relieve her fears. Which medication is U.S. Food and Drug Ad-
ministration (FDA) approved for use in this girl?

A. Fluvoxamine.
B. Sertraline.
C. Fluoxetine.
D. Citalopram.

36.4 Of the most commonly used alternative or complementary remedies for depres-
sive and anxiety disorders—St. John’s wort, omega-3 fatty acid, and S-adenosyl-
methionine—which has some limited randomized controlled trial (RCT) evi-
dence indicating potential benefit of its use in pediatric depressive or anxiety dis-
orders?

A. Omega-3 fish oil, when used in children with depression.

B. St. John’s wort, when used in children with anxiety disorders.

75
 C. S-adenosyl-methionine, when used in children with depression.
D. S-adenosyl-methionine, when used in children with anxiety disorders.

36.5 Which antidepressant has U.S. Food and Drug Administration (FDA) approval
for treatment of depression in both children and adolescents?

A. Citalopram.
B. Escitalopram.
C. Venlafaxine.
D. Fluoxetine.

76 | Antidepressants—Questions
 C H A P T E R 3 7

Mood Stabilizers
37.1 Which surveillance study should be performed at least every 6 months in children
and adolescents taking lithium?

A. Electrocardiogram (ECG).
B. Calcium level.
C. Thyroid function tests.
D. High-level ultrasound.

37.2 Which mood stabilizer is the only one approved by the U.S. Food and Drug Ad-
ministration (FDA) for the treatment of manic episodes of bipolar illness in pa-
tients ages 12 years and older?

A. Valproate.
B. Lithium carbonate.
C. Long-acting form of carbamazepine.
D. Lamotrigine.

37.3 A 16-year-old girl develops weight gain, acne, hirsutism, and irregular menstrua-
tion after 6 months of medication treatment for bipolar disorder. She is evaluated by
an endocrinologist who diagnoses polycystic ovarian syndrome (PCOS). Which
mood stabilizer is most commonly associated with this condition?

A. Lithium.
B. Valproate.
C. Carbamazepine.
D. Lamotrigine.

37.4 The addition of carbamazepine may result in increased levels of which of the fol-
lowing medications?

A. Oral contraceptives.
B. Phenobarbital.
C. Lithium.
D. Valproate.

77
37.5 What is the frequency of serious rash (requiring hospitalization and discontinua-
tion of treatment) associated with lamotrigine in children under the age of 16 years?

A. 1 per 100.
B. 3 per 1,000.
C. 1–6 per 10,000.
D. 10 per 10,000.

78 | Mood Stabilizers—Questions
 C H A P T E R 3 8

Antipsychotic
Medications
38.1 Which of the following antipsychotic side effects is most common among children
and adolescents?

A. Weight gain.
B. Diabetes or tardive dyskinesia.
C. Abnormal liver enzymes.
D. Neutropenia.

38.2 Which one of the following is a U.S. Food and Drug Administration (FDA)–
approved indication for antipsychotic use in youth?

A. Schizotypal personality disorder.

B. Oppositional defiant disorder.
C. Irritability associated with autism spectrum disorder.
D. Obsessive-compulsive disorder.

38.3 The central pharmacodynamic feature of all antipsychotics is their ability to do

which of the following?

A. Block the dopamine D1 receptor.

B. Block the dopamine D2 receptor.
C. Bind to serotonin receptors.
D. Bind to histamine receptors.

38.4 What metabolic feature of antipsychotics can be associated with sexual side effects?

A. QTc prolongation.
B. Hyperprolactinemia.
C. Sedation.
D. Liver enzyme abnormalities.

79
38.5 Which of the following is a tertiary prevention strategy?

A. Choosing an agent with the lowest likelihood of adverse effects on body com-
position and metabolic status.
B. Intensified weight reduction interventions.
C. Intensification of healthy lifestyle instructions.
D. Consideration of switching to a lower-risk agent.

80 | Antipsychotic Medications—Questions
 C H A P T E R 3 9

Individual Psychotherapy
39.1 Which psychodynamic construct is defined as the psychological space (and ener-
gies) occupied by ways of coping, defending against the drives, thinking things
through, and dealing with loved ones and the world—both conscious and uncon-
scious?

A. Id.
B. Ego.
C. Superego.
D. Ego ideal.

39.2 If a therapist working with a child is taking a supportive approach in the psycho-
therapy treatment, the therapist might employ which of the following tech-
niques?

A. Interpretation.
B. Clarification.
C. Modeling.
D. Maintenance of a neutral stance.

39.3 What phenomenon is regarded by some as less important in the treatment of

young children than in treatment of adults because children are still primarily in-
volved in their families of origin?

A. Correction.
B. Abreaction.
C. Repetition compulsion.
D. Transference.

39.4 A therapist who is treating a child while one or more other clinicians treat the par-
ent(s) or sibling(s) is engaging in what form of treatment?

A. Supportive psychotherapy.
B. Family therapy.
C. Collaborative therapy.
D. Filial therapy.

81
 C H A P T E R 4 0

Parent Counseling,
Psychoeducation, and
Parent Support Groups
40.1 Psychoeducation originally emerged as a therapeutic component in the treatment
of what psychiatric disorder?

A. Autism.
B. Major depressive disorder.
C. Substance abuse.
D. Schizophrenia.

40.2 Psychoeducational programs designed for adults generally require what adaptation
to be used in child populations?

A. Lower intensity.
B. Shorter follow-up.
C. Emphasis on improving the home environment.
D. Emphasis on changing the child’s behavior to meet the expectations of the
school environment.

40.3 Multifamily psychoeducational psychotherapy (MF-PEP) was developed for use

in what population?

A. Toddlers with pervasive developmental disorders.

B. Preschoolers with behavioral problems.
C. Children with mood disorders.
D. Adolescents with substance use disorders.

40.4 Parents participating in parent support services find what aspect of the services to
be most helpful?

A. Practical information.
B. Sense of shared purpose or advocacy.

83
 C. Access to specialized mental health care.
D. Emotional support.

40.5 What is the psychoeducational technique that involves the use of written materi-
als, video, or Web sites to further educate families about mental illness?

A. Bibliotherapy.
B. Naming the enemy.
C. Thinking, feeling, doing.
D. Daily routine tracking.

84 | Parent Counseling and Psychoeducation—Questions

 C H A P T E R 4 1

Behavioral Parent Training

41.1 Which contingency-based behavioral key concept involves decreasing a behavior
by following it with something undesirable?

A. Positive reinforcement.
B. Negative reinforcement.
C. Punishment.
D. Extinction.

41.2 Within what period from the time that parents put initial strategies of behavioral
parent training (BPT) into practice do children typically respond?

A. Several days.
B. Several weeks.
C. Several months.
D. >6 months.

41.3 What is a primary contraindication for behavioral parent training (BPT)?

A. Parent with severe depression.

B. Toddler with oppositionality and comorbid attention-deficit/hyperactivity dis-
order (ADHD).
C. Parent and child with poor attachment.
D. Adolescent with behavioral problems and comorbid anxiety.

41.4 If a token economy is not initially effective, which of the following would be an
error discovered upon troubleshooting the intervention?

A. The target behavior is defined vaguely to increase the likelihood of success.

B. The goal is set at a level that allows the child to be successful immediately.
C. The reinforcer is given immediately and frequently.
D. The child can get the reinforcer only when earned.

85
41.5 Which of the following is a theoretical underpinning and key concept in behav-
ioral parent training (BPT)?

A. Behavioral therapy approaches emphasize classical conditioning theory.

B. Behavioral interventions usually begin with a functional behavior analysis,
which involves specifying behaviors and then identifying each behavior’s an-
tecedents and consequences.
C. Maximally effective interventions do not consider the function of the problem
behavior when attempting to reduce it.
D. The behavioral approach to intervention selects target diagnostic symptoms
for treatment.

86 | Behavioral Parent Training—Questions

 C H A P T E R 4 2

Family-Based Assessment
and Treatment
42.1 During the early to mid twentieth century, what led to the belief that parents
should not be involved in child treatment?

A. Parents were regarded as the cause of their child’s psychological or psychiatric

problems.
B. Research had established that family involvement negatively affected treat-
ment engagement and dropout rates in child mental health.
C. Research had found that integration of parent support into child treatment led
to child symptom exacerbation.
D. Research had found that integration of parent support into child treatment led
to parental dissatisfaction with the treatment.

42.2 What concept involves the provision of a safe and need-fulfilling social context
within which the infant and young child can develop?

A. Negative affective reciprocity.

B. Systems principle.
C. Multilevel principle.
D. Holding environment.

42.3 Which of the following has been identified in dyadic and family-based treatments
as enhancing positive outcome?

A. Creating good alliance with the family members who demonstrate the most
motivation for change.
B. Conceptualizing problems to be the responsibility of the identified patient.
C. Slowing down and softening the interactive and emotional processes.
D. Encouraging personal responsibility solely for positive processes.

87
42.4 What tenet did Jay Lebow highlight in his influential 1997 article identifying a dra-
matic change in family therapy practice?

A. Clinicians should practice within one theoretical model or treatment modality.

B. Clinicians should remain loyal to older theoretical models.
C. Clinicians should abandon empirically supported treatments.
D. Clinicians should be integrative and “do what works.”

42.5 What is a distinguishing aspect of Integrative Module-Based Family Therapy

(IMBFT)?

A. While involving domains that are empirically established or reasonably as-

sumed mechanisms of change, it typically is considered to be less comprehen-
sive than other forms of family therapy.
B. It typically focuses on the specific family to the exclusion of the role that cul-
ture, socioeconomic level, immigration status, religion, race, gender, and sex-
ual orientation can play in producing and maintaining psychopathology.
C. Despite the inclusion of a step-by-step assessment instrument, it was designed
to be flexible and responsive to changing clinical presentations or new challenges
that affect treatment.
D. It is a self-contained treatment modality that obviates the need for the clinician
to search the literature and/or use additional tools (e.g., symptom rating scales,
standard checklists, etc.).

88 | Family-Based Assessment and Treatment—Questions

 C H A P T E R 4 3

Interpersonal Psychotherapy
for Depressed Adolescents
43.1 What is the main treatment focus of interpersonal psychotherapy for depressed
adolescents (IPT-A)?

A. Changing maladaptive beliefs and attitudes, eliminating emotional distress,

and alleviating social skill deficits and avoidance behaviors.
B. Improving the adolescent’s relationships by teaching communication and in-
terpersonal problem-solving skills that can lead to a reduction in the adoles-
cent’s depressive symptoms.
C. Strengthening a person’s own motivation and commitment to change.
D. Internal conflict, the unconscious, repetition compulsion, and transference.

43.2 What process is involved in the initial phase of interpersonal psychotherapy for
depressed adolescents (IPT-A) in providing psychoeducation about depression to
an adolescent?

A. Confirming the depression diagnosis.

B. Assigning the adolescent the limited sick role.
C. Identifying effective strategies for managing the problem and practicing and
implementing the strategies.
D. Discussing the possibility of recurrence of depression, the warning symptoms
of depression that are particular to that adolescent, and strategies for manag-
ing a recurrence.

43.3 What is the purpose of the interpersonal inventory?

A. To identify ways in which an adolescent’s communication is problematic and

skills the adolescent needs to master to have more satisfying relationships.
B. To select an interpersonal situation that is causing the adolescent problems,
determine the goal, generate a list of alternative strategies, evaluate the pros
and cons of each potential solution or strategy, and select a strategy to try.

89
 C. To identify the interpersonal issues that are most closely related to the adoles-
cent’s depression.
D. To practice the communication and interpersonal problem-solving skills.

43.4 In which interpersonal problem area are renegotiation, impasse, and dissolution
stages described?

A. Grief due to death.

B. Interpersonal role disputes.
C. Interpersonal role transitions deficits.
D. Interpersonal deficits.

43.5 For which patients is interpersonal psychotherapy for depressed adolescents

(IPT-A) most effective?

A. Adolescents with a primary diagnosis of anxiety and comorbid depression.

B. Adolescents with a primary diagnosis of bipolar disorder with a current depres-
sive episode.
C. Adolescents with a primary diagnosis of depression and concurrent passive sui-
cidal thoughts.
D. Adolescents with a primary diagnosis of depression and comorbid intellectual
disability.

90 | Interpersonal Psychotherapy for Depressed Adolescents—Questions

 C H A P T E R 4 4

Cognitive-Behavioral
Treatment for Anxiety and
Depression
44.1 Which is the process by which a child may acquire a fear by observing another
person behaving fearfully?

A. Classical conditioning.
B. Operant conditioning.
C. Vicarious conditioning.
D. Cognitive restructuring.

44.2 Over the course of several weeks, a 7-year-old girl with social anxiety disorder
has worked her way with her therapist through her social anxiety “ladder.” She
has worked on speaking to staff at the clinic with and then without her therapist
and then on speaking to the familiar cashier at a neighborhood store with and
then without her therapist. She next plans to speak to a stranger on the street be-
fore finally speaking in front of her class at school. This therapeutic approach il-
lustrates which of the following cognitive-behavioral therapy (CBT) strategies?

A. Social skills training.

B. Graduated exposure.
C. Relaxation training.
D. Cognitive restructuring.

44.3 Research does not yet support the use of cognitive-behavioral therapy (CBT) for
which age group?

A. Very young children (e.g., ages 3–5 years) with depression.

B. Children (e.g., ages 7–11 years) with anxiety.
C. Adolescents (e.g., ages 12–17 years) with depression.
D. Adolescents (e.g., ages 12–17 years) with anxiety.

91
44.4 When compared to other anxiety disorders, which anxiety disorder in youth may
present unique treatment challenges and may not be most efficaciously treated
with a generic or transdiagnostic intervention strategy?

A. Generalized anxiety disorder.

B. Specific phobia.
C. Separation anxiety disorder.
D. Social anxiety disorder.

44.5 Which of the following factors seems to significantly affect cognitive-behavioral

therapy (CBT) treatment outcome for youth with anxiety disorders?

A. Ethnicity.
B. Gender.
C. Socioeconomic status.
D. Parental psychopathology.

44.6 Which of the following has been established regarding BRAVE-Online, an Inter-
net-based cognitive-behavioral therapy (CBT) program developed for delivery to
youth with anxiety disorders?

A. In a sample of adolescents, BRAVE-Online was less effective in decreasing anx-

iety than was BRAVE delivered in the clinic.
B. BRAVE-Online is less effective for youth with severe anxiety than for youth with
anxiety of less severity.
C. In a sample of 7- to 12-year-old children, BRAVE-Online led to small positive
changes.
D. BRAVE-Online was more effective in a sample of 7- to 12-year-old children than
it was for a sample of adolescents.

92 | Cognitive-Behavioral Treatment for Anxiety and Depression—Questions

 C H A P T E R 4 5

Motivational Interviewing
45.1 What makes motivational interviewing (MI) different from traditional patient-
centered approaches?

A. MI combines outcome with strategy.

B. The theoretical basis for MI is psychodynamic theory.
C. MI typically focuses on education-delivery and provider-centered ideas for
change, as these techniques are known to be effective.
D. MI is deliberate, directional, and goal oriented.

45.2 According to the spirit of motivational interviewing (MI), which of the following
should the provider express to, as opposed to evoke from, the patient?

A. Confidence.
B. Empathy.
C. Hope.
D. Action.

45.3 Which of the following interview skills can be a very useful way of guiding
change but in motivational interviewing (MI) is typically only exercised with the
permission and readiness of the patient?

A. OARS.
B. Affirmations.
C. Information sharing.
D. Summaries.

45.4 How should a provider attempt to resolve parent-child conflict using motivational
interviewing (MI)?

A. Elicit self-motivational statements by asking the “DARN CAT” questions of

the child.
B. Focus on factors within the parent’s control, unless the child is younger than
age 8 years.
C. Relieve discomfort by spreading the blame in a family.
D. Align parent and child in pursuit of a common goal.

93
45.5 When is it appropriate to negotiate a change with a patient in motivational inter-
viewing (MI)?

A. During agenda-setting.
B. When the situation is serious from a safety perspective.
C. When attempting to focus.
D. When planning for change.

94 | Motivational Interviewing—Questions
 C H A P T E R 4 6

Systems of Care,
Wraparound Services, and
Home-Based Services
46.1 Which of the following reflects a guiding principle of a system of care (SOC)?

A. Services should be standardized for all children and families.

B. Services should be developmentally appropriate and quickly engage the highest
and most intensive possible level of care.
C. To promote autonomy for the youth, caregivers should be limitedly integrated
into the treatment process.
D. Services should be integrated and linked to one another.

46.2 Which of the following is a key characteristic of wraparound?

A. The use of a deficit model.

B. An approach that identifies a problem and focuses on ameliorating the problem.
C. The value placed on cultural competence.
D. The co-construction by a physician and case manager of a treatment plan.

46.3 What was the intent of the Adoption Assistance and Child Welfare Act of 1980?

A. To strengthen permanency planning for children.

B. To create a national network of community mental health centers.
C. To create funding for family preservation and family support programs.
D. To enable children with special needs to access services without resorting to
the juvenile justice or child protective service systems.

46.4 Multisystemic therapy (MST) has a robust evidence base for use with which pop-
ulation?

A. Adults with psychiatric problems as a primary concern.

B. Youth with psychiatric problems as a primary concern.
C. Adults at risk for incarceration.
D. Juvenile offenders and substance-abusing youth.
95
 C H A P T E R 4 7

Milieu Treatment
Inpatient, Partial Hospitalization, and
Residential Programs
47.1 What intervention targets impulsive aggression, noncompliance, and engage-
ment in therapy; is increasingly being employed in milieu therapy programs; and
is especially useful for suicidal and self-injurious youth?

A. Repeated seclusion and restraint.

B. Level systems.
C. Dialectical behavior therapy (DBT).
D. Chemical restraint and as-needed (prn) sedation.

47.2 Outcome studies of residential treatment centers suggest that which of the follow-
ing factors is associated with a positive outcome?

A. Exiting at the lowest level of restrictedness.

B. Organic etiology for the psychiatric disorder.
C. Presence of psychosis.
D. Below-average level of intelligence.

47.3 What variable is the most consistent, largest predictor of length of stay (LOS) for
youth admitted to an inpatient hospital unit?

A. Suicide risk.
B. Dangerousness to others.
C. Consistency of symptoms across multiple contexts.
D. The hospital itself.

47.4 Which of the following was a result of a study by Katz et al. (2004) that compared
the outcomes for two groups of suicidal adolescents—one group that received di-
alectical behavior therapy (DBT) administered in 10 daily sessions on one acute
hospital unit and another group that received treatment as usual (TAU, compris-
ing psychodynamically oriented crisis assessment and treatment) on a matched
unit?

97
 A. The DBT group had significantly fewer behavioral incidents during hospital-
ization.
B. The DBT group had a shorter mean LOS.
C. The DBT group demonstrated a significant reduction in suicidality at 1-year
follow-up, whereas the TAU group did not.
D. The TAU group demonstrated a significant reduction in depressive symptoms
at 1-year follow-up, whereas the DBT group did not.

47.5 With what problem do youth most frequently present to acute specialty mental
health inpatient programs?

A. Aggression.
B. Delinquent behavior.
C. Depressed or anxious mood (including self-harm).
D. Suicidality.

47.6 Outcome studies of partial hospitalization/day treatment programs suggest which

of the following?

A. All children can benefit from this service or be reintegrated into school settings.
B. Individual functioning improves, but family functioning does not.
C. Gains are not generalized to the school setting.
D. Families play noncritical roles posttreatment.

98 | Milieu Treatment—Questions
 C H A P T E R 4 8

School-Based Interventions
48.1 Of the following descriptions of models of school consultation and direct service,
which refers to the case consultation model?

A. In this model, clinicians advise school personnel about appropriate educational

and/or therapeutic approaches to and/or services for individual students
with developmental, cognitive, emotional, behavioral, or social problems.
B. In this model, clinicians are engaged by the school to advise school personnel
about the creation of a milieu that is conducive to learning.
C. In this model, mental health services are delivered in the context of a school-
based health center.
D. In this model, schools are linked with hospitals or community clinics that are
contracted to provide medical and mental health services to students at con-
venient locations off site from the school.

48.2 Which of the following is a provision in the Individuals With Disabilities Educa-
tion Act (IDEA)?

A. Eligibility of a child for special education services if he or she meets criteria for
one or more categories of disability and if the disability substantially interferes
with his or her educational progress.
B. The creation of a partnership between schools and community agencies and
programs to move toward a full continuum of mental health services.
C. The mandated inclusion without discrimination for any person who has a
“physical or mental impairment that substantially limits a major life activity.”
D. The prohibition of discrimination through its equal protection clause.

48.3 As required by federal guidelines, within what time period must the school com-
plete the conducted special education evaluation after receiving parental consent?

A. 30 calendar days.
B. 60 calendar days.
C. 90 calendar days.
D. 180 calendar days.

99
48.4 Which of the following describes the Good Behavior Game?

A. It is a classroom-wide, teacher-delivered intervention in which teachers in early

elementary grades model and reinforce student behaviors identified by the
schools as promoting a positive learning environment.
B. It posits that continual behavioral coaching combined with acknowledgment
of positive student behavior will reduce unnecessary disciplinary actions and
promote a climate of greater productivity, safety, and learning.
C. It targeted elementary school students and focused on teacher training, child
skill development, and parent training.
D. It targeted high school students and focused on developing cognitive and in-
terpersonal skills and creating an environment that enhanced connectedness.

48.5 What are universal preventive interventions?

A. They are intended to prevent the development of symptoms in high-risk stu-

dents and as such are targeted at students exhibiting risk factors for psychiat-
ric disorders.
B. They are intended to prevent the escalation of subsyndromal symptoms of psy-
chiatric disorders to syndromal disorders and as such are targeted at students
exhibiting symptoms.
C. They are intended to promote mental health and as such are targeted at all stu-
dents, regardless of risk status.
D. They are intended to treat psychiatric disorders and are targeted at students
with psychiatric diagnoses.

100 | School-Based Interventions—Questions

 C H A P T E R 4 9

Collaborating With
Primary Care
49.1 What was the Triple Aim of the 2010 Affordable Care Act as it related to behavioral
health care?

A. Saving costs, reducing hospital admissions, and forming accountable care or-
ganizations and patient-centered medical homes.
B. Improving coverage of behavioral health treatment, calling for increased pro-
vider accountability to improve access to and the experience of care and quality
of care provided, and doing so at significant cost savings.
C. Expanding collaborative care, integrated care, and child psychiatry access
programs.
D. Mandating that psychiatrists consult with, collaborate with, and teach and men-
tor primary care physicians (PCPs).

49.2 How does the cost of care for treating a medical condition change when the indi-
vidual has a co-occurring mental illness or substance use disorder?

A. It decreases by 50%.
B. It decreases at least two to three times.
C. It increases by 50%.
D. It increases at least two to three times.

49.3 What is typically meant by the term collaborative care?

A. A team of primary care and behavioral health clinicians, working together with
patients and families.
B. An alliance and partnership between various providers and/or agencies in or-
der to provide effective care coordination across behavioral health and primary
care.
C. Enhancing the availability of child psychiatrists in urban populations.
D. The screening of patients by psychiatrists for signs and symptoms of and risks
for mental health problems.

101
49.4 What is an expectation for the role of primary care in the mental health care of
children?

A. As part of the care of the well child and routine health maintenance, the primary
care physician (PCP) will provide comprehensive psychiatric treatment for pa-
tients with mental health problems.
B. The PCP will screen for and identify signs and symptoms of and risks for men-
tal health problems.
C. The PCP will defer all monitoring of treatment effectiveness to the psychiatrist.
D. The PCP always primarily manages the mental health care of the child.

49.5 Providing mental health care in the primary care clinic requires that the pediatrician
or family physician do which of the following?

A. Establish local or regional connections with mental health professionals to

participate as team members in the patient’s care.
B. Locate a mental health professional within driving distance from the clinic.
C. Allow providers to use their own screening protocols, triage and referral pro-
cesses, and treatment and monitoring pathways.
D. Minimize connection among psychiatrists, psychologists, social workers, ad-
vanced practice nurses (APNs), and the primary care physician (PCP) to avoid
confusion.

49.6 A 9-year-old patient was diagnosed with attention-deficit/hyperactivity disorder

several years ago; he experienced failed trials of methylphenidate and atomoxe-
tine. He repeated third grade this year, and his school recommends that the stu-
dent again repeat third grade. With his worsening behavior, the school is reluctant
for him to return in the fall. At home, his parents have struggled controlling his
behavior: he is not responding to behavior limitations and is at times rough with
his infant sister. The boy is well medically, and the pediatrician does not feel she
has to see the patient regularly any longer. On the collaborative care spectrum,
what level of care is most ideal for this patient?

A. Primarily primary care.

B. Primarily primary care with consultation.
C. Shared care.
D. Primarily mental health care.

49.7 How is improved collaboration between primary care physicians (PCPs) and child/
adolescent psychiatrists beneficial for children who require mental health care?

A. Collaboration increases access to mental health care for children and reduces
cost of providing care.
B. Collaboration decreases communication between PCPs and psychiatrists.
C. Collaboration limits screening of patients for childhood psychiatric diagnoses.
D. Collaboration leads to all children accessing more intensive level of services.

102 | Collaborating With Primary Care—Questions

49.8 Which of the following describes the consultative role of child and adolescent
psychiatrists in regard to effective screening?

A. Psychiatrists do not have screening methods or perform interpretations because

paraprofessional staff can do this.
B. Psychiatrists may recommend screening tools without concern for appropriate
follow-up strategies and resources.
C. Psychiatrists can provide technical support in the selection of appropriate screen-
ing instruments and screening methodology and assist in the follow-up as-
sessment of patients with positive screens.
D. Psychiatric consultants should not be involved in choosing screening tools.

Collaborating With Primary Care—Questions | 103

 PART II

Answer Guide
 C H A P T E R 1

The Process of Assessment

and Diagnosis
1.1 Which of the following is used to assess normality and deviation from normality
of what the average expectable child will be like at any given age?

A. Mentalization.
B. Developmental framework.
C. Biopsychosocial model.
D. Cognitive restructuring.

The correct response is option B: Developmental framework.

Mentalization is the ability to infer others’ emotions and intent (option A is incor-
rect). The evaluation of any child requires the use by the clinician of a develop-
mental framework. The clinician, through his or her knowledge of development,
has in mind an idea of what the average expectable child will be like at any given
age. The child’s developmental profile will be compared with a developmental
standard as the clinician seeks to discover if this child’s behavior or degree of
competence in any particular area differs significantly from that of the child’s
peers. The pediatrician uses height and weight charts to assess a child’s physical
growth. The psychiatric clinician does not have such specifics but applies the
same process of evaluation of normality and deviation from it (option B is correct).
Formulations are typically organized in one of two ways: using a biopsychosocial
approach or a shortened form of a temporal axis (Ebert et al. 2000, pp. 520–521).
In the biopsychosocial model, those variables that influence the child and family
to present in their current state are grouped into three categories: biological, psy-
chological, and social. Biological factors include, but are not limited to, genetic
factors, pregnancy and birth factors, and medical illnesses. Some examples of psy-
chological factors are the child’s and family’s level of development, self-esteem,
and ego defenses. Social variables include family functioning, spiritual and cul-
tural issues, and peers (option C is incorrect). Cognitive restructuring is based on
the theory that negative thoughts can affect the emotional and behavioral response
to the anxiety-provoking situations. The goal of treatment is to restructure faulty

107
 cognitions, which in turn should decrease subjective distress and eliminate avoid-
ance behavior (option D is incorrect). (Chapter 1, The Process of Assessment and
Diagnosis, pp. 4, 10; Chapter 8, Autism Spectrum Disorders, pp. 135–136; Chap-
ter 44, Cognitive-Behavioral Treatment for Anxiety and Depression/General
Characteristics of Cognitive-Behavioral Treatment/Anxiety Disorders, p. 975)

1.2 How do adult assessments differ from child assessments?

A. In adult assessments, the prime source of information is typically the patient;

in child assessments, the information is typically provided by the child and his
or her teacher.
B. With adults, the interchange between psychiatrist and adult patient is generally
verbal; with youth of any age, the role of play is central in the evaluation process.
C. Adults typically are brought to the evaluation and rarely seek it out, whereas
children generally participate volitionally in the evaluation.
D. With adults, their usually positive expectations of seeing a psychiatrist pro-
vide motivation for the initial phases of evaluation; with children, most do not
see the doctor as particularly helpful, and therefore the psychiatrist frequently
has to work much harder to establish a working relationship with the child.

The correct response is option D: With adults, their usually positive expecta-
tions of seeing a psychiatrist provide motivation for the initial phases of eval-
uation; with children, most do not see the doctor as particularly helpful, and
therefore the psychiatrist frequently has to work much harder to establish a
working relationship with the child.

The prime source of information in the evaluation of an adult is the person him-
self or herself. There are some exceptions to this, particularly in the geriatric pop-
ulation, where other informants, especially caregivers, are needed. It would be
quite unusual for a psychiatrist to request information from the employer of an
adult patient. However, multiple sources, especially the parents, constitute the field
for data collection with children (option A is incorrect). The interchange between
psychiatrist and adult patient is generally verbal, with some data gathered from
nonverbal communication. While this is true for most adolescents, the younger
the child, the more central is the role of play in the evaluation process (option B is
incorrect). The issue of volitional participation is another area of difference be-
tween adult assessment and child assessment. Children are brought to the evalu-
ation; they rarely seek it out. Infants and children are brought because, in general,
their behavior is bothersome to others, not necessarily to themselves (option C is
incorrect). The concept of the psychiatrist as expert is not easily grasped by a child.
Adults generally see the psychiatrist as someone from whom they can benefit,
even though they may approach the process with trepidation. Most children do
not see the doctor as particularly helpful. In fact, children are wary of the experience
and often see the psychiatrist as an annoyance—someone who takes them away
from their baseball game, video game, and so forth. The usual positive expectations
that provide motivation for the initial phases of adult evaluation are absent with

108 | The Process of Assessment and Diagnosis—Answer Guide

 children. Thus, the child and adolescent psychiatrist has to work much harder to es-
tablish rapport and a working relationship with the child, who often regards him
or her with suspicion or even as an agent of the parents or the school (option D is
correct). (Chapter 1, The Process of Assessment and Diagnosis/Comparison of
Adult Assessment With Child Assessment, p. 4)

1.3 Why do child psychiatrists generally see contacting the school as a necessary and
vital part of a complete evaluation of a child or adolescent?

A. Because data regarding the child’s academic status and progress are needed.
B. Because information regarding the child’s social relatedness to peers (but not
adults) is needed.
C. Because information regarding the teachers’ comparisons of the child to his or
her older-aged peers is helpful.
D. Because school staff members are the major source of data regarding how the
child views himself.

The correct response is option A: Because data regarding the child’s academic
status and progress are needed.

In an overwhelming majority of child assessments, information from the school

is needed regarding not only academic status but also social relatedness to peers
and adults (option A is correct; option B is incorrect). A child psychiatrist sees
contacting the school and other agencies as a necessary and vital part of a com-
plete evaluation. Children are strongly affected by their environment, and the
evaluation needs to take that into account.
Teachers spend long periods of time with the child, and they observe the child’s
response to work demands and learning. They are able to compare the child with
same-age peers (option C is incorrect). All too frequently neglected is how the
child views himself. Collateral information can be gathered from parents and the
school, but the major source of data is the child himself or herself (option D is in-
correct). Often the child’s view of himself or herself cannot be assessed directly.
The clinician must use indirect means, such as drawings, dreams, and fantasy ques-
tions. (Chapter 1, The Process of Assessment and Diagnosis/Comparison of Adult
Assessment With Child Assessment, p. 5; Data Collection, p. 6; Other Sources
of Data, p. 9)

1.4 When using the temporal axis schema proposed by Ebert et al. (2000) to organize
a formulation, which factors are defined as stressors that test the individual’s cop-
ing mechanisms and cause signs and symptoms to occur?

A. Biological factors.
B. Perpetuating factors.
C. Psychological factors.
D. Precipitating factors.

The correct response is option D: Precipitating factors.

The Process of Assessment and Diagnosis—Answer Guide | 109

 Formulations are typically organized in one of two ways: using a biopsychosocial
approach or a shortened form of a temporal axis (Ebert et al. 2000, pp. 520–521).
In the biopsychosocial model, those variables that influence the child and family
to present in their current state are grouped into three categories: biological, psy-
chological, and social. Biological factors include, but are not limited to, genetic
factors, pregnancy and birth factors, and medical illnesses (option A is incorrect).
Some examples of psychological factors are the child’s and family’s level of devel-
opment, self-esteem, and ego defenses (option C is incorrect). Social variables in-
clude family functioning, spiritual and cultural issues, and peers. Ebert et al.
(2000) suggest another viewpoint—that of looking at factors along a time axis
grouped as predisposing, precipitating, perpetuating, and prognostic. Predispos-
ing factors are genetic heritability, intrauterine or perinatal insults, neglect, and so
forth. Precipitating factors are defined as stressors (e.g., physical illness, loss, divorce)
that test the coping mechanisms and cause signs and symptoms to occur (option D
is correct). Perpetuating factors (e.g., continuous trauma, parental style) are those that
reinforce symptomatology (option B is incorrect). Prognostic factors are those that
influence a child’s symptom future, duration of illness, severity of illness, time of
onset of illness, and so forth. Regardless of which system the clinician uses, “a for-
mulation is necessary to sift, prioritize, and integrate the data for treatment plan-
ning” (Jellinek and McDermott 2004, p. 913). The formulation leads to a differen-
tial diagnosis wherein the clinician considers the most likely diagnoses and
chooses one or more that are consistent with the data. The purpose of the entire
process is to make treatment recommendations tailored for the child and the family.
(Chapter 1, The Process of Assessment and Diagnosis/Formulation, pp. 10–11)

1.5 Which of the following is a purpose of the interpretive or feedback interview?

A. To inform the parents alone of what the clinician has found.

B. To inform the parents and child of what the clinician has decided will be done
to address the issues for which they came.
C. To help parents understand that human behavior, especially children’s behav-
ior, typically is shaped by a single cause for which intervention exists.
D. To help parents realistically appraise their situation and their child.

The correct response is option D: To help parents realistically appraise their sit-
uation and their child.

The purpose of the interpretive or feedback interview is to inform the parents and
child what has been found (option A is incorrect) and what the clinician, with
their help, would recommend to address the issues for which they came (option
B is incorrect). The clinician shares with the family the process of treatment plan-
ning. What are the family’s thoughts about the goals and objectives, and how re-
alistic and applicable are they to the family situation? The more active the parents
are in setting up the treatment, the more likely they are to participate in the treat-
ment process and facilitate their child’s participation. Parents may need help to
understand that human behavior, especially children’s behavior, is shaped by

110 | The Process of Assessment and Diagnosis—Answer Guide

 many interacting variables, not a single cause, and because of this complexity,
multiple interventions may be needed (option C is incorrect). A major objective of
the feedback session is to help parents realistically appraise their situation and
their child (option D is correct). This is especially true for children who have a de-
velopmental disability or a chronic illness. In these circumstances, parents need
to reevaluate the child and their expectations of the child (O’Brien et al. 1992). For
these parents, “the primary issue that has to be worked through is the loss and
subsequent mourning of the idealized child” (O’Brien et al. 1992, p. 113). (Chapter
1, The Process of Assessment and Diagnosis/Interpretative or Feedback Inter-
view, pp. 12–13)

References
Ebert MH, Loosen PT, Nurcombe B: Current Diagnosis and Treatment in Psychiatry. New York,
McGraw-Hill, 2000
Jellinek MS, McDermott JF: Formulation: putting the diagnosis into a therapeutic context and
treatment plan. J Am Acad Child Adolesc Psychiatry 43(7):913–916, 2004 15213593
O’Brien JD, Pilowsky D, Lewis O: Psychotherapies With Children and Adolescents: Adapting the
Psychodynamic Process. Washington, DC, American Psychiatric Press, 1992

The Process of Assessment and Diagnosis—Answer Guide | 111

 C H A P T E R 2

Assessing Infants and

Toddlers
2.1 Which of the following most closely predicts an infant or toddler’s ability to remain
resilient in the face of stress?

A. Environmental factors.
B. Caregiving relationships.
C. Intrinsic risk factors.
D. Biological processes.

The correct response is option B: Caregiving relationships.

In isolation, the individual characteristics of the infant or toddler have limited

predictive value for the child’s future development. The child’s important care-
giving relationships, on the other hand, are far more predictive of subsequent out-
comes (Shonkoff et al. 2012) (option B is correct). Environmental risks exert their
effect on the young child primarily through the caregiving relationship (option A
is incorrect). Intrinsic risk factors and biological processes can be moderated by
the infant’s caregiving relationships (options C and D are incorrect). Infants who
develop a secure attachment relationship with a primary caregiver during the first
year of life are more likely to have positive relationships with peers, to be liked by
their teachers, to perform better in school, and to be more resilient in the face of
stress or adversity as preschoolers and later. The infant–caregiver relationship can
serve as a buffer against adversity or can compound other risk factors. (Chapter 2,
Assessing Infants and Toddlers/Relational Approach to Assessing Infants and
Toddlers, pp. 18–19)

2.2 At what developmental age does separation from caregivers activate the child’s
attachment system?

A. Birth to 2 months.
B. 2–7 months.
C. 7–9 months.
D. 18–36 months.

113
 The correct response is option C: 7–9 months.

Advancing stages of social-emotional development are typically observed during

specific age ranges. Once a child reaches 7–9 months of developmental age, sep-
aration from caregivers activates the child’s attachment system, which is mani-
fested by separation anxiety and separation distress (option C is correct). As seen
in Table 2–1, from birth to 2 months, infants demonstrate a quiet, alert state evident
for minutes at a time (option A is incorrect). Infants ages 2–7 months may exhibit
social smiling and sustained eye-to-eye contact (option B is incorrect). Awareness
of relationship to group, more emphasis on personal possessions, and moral emo-
tions such as shame, guilt, and pride may be observed in children ages 18–36 months
(option D is incorrect). (Chapter 2, Assessing Infants and Toddlers/Comprehen-
sive Assessment/Observations, pp. 26–27; Table 2–2, p. 27)

2.3 What does the Insightfulness Assessment (IA) measure?

A. Parent’s ability to take the infant’s perspective.

B. Parent’s primary defensive strategy.
C. Parent’s understanding of his or her child and of the relationships they share.
D. Multiple domains of the parent–child relationship, including reciprocal emotions.

The correct response is option A: Parent’s ability to take the infant’s perspective.

The IA specifically measures a parent’s ability to take the infant’s perspective

(Oppenheim and Koren-Karie 2002) (option A is correct). In this procedure, par-
ents are interviewed after reviewing a video of themselves interacting with their
child in a structured set of interactions. The interview focuses on each parent’s
understanding of what the child was feeling and how the parent felt during the
video replay.
The Circle of Security treatment model includes an interview developed spe-
cifically for use in that clinical intervention model. Derived from the Adult At-
tachment Interview and the Parent Development Interview, the Circle of Security
Interview also includes questions about the parent’s experience of participating
in the Strange Situation procedure (Cooper et al. 2009). From the interview, clini-
cians can identify the parent’s primary defensive strategy or “core sensitivity” from
one of three categories: esteem sensitive, safety sensitive, and separation sensitive
(option B is incorrect).
The working model of the child interview is an approximately 1-hour interview
focused on a parent’s understanding of his or her child and of the relationship they
share (available at www.infantinstitute.com/training) (option C is incorrect).
During this interview, the parent is asked about the child’s personality and the re-
lationship he or she has with the child. The content of the parent’s responses can be
useful information about the parent’s experience of the infant or toddler.
In the Crowell procedure (Crowell and Feldman 1988), the parent and child (of
at least 6 months developmental age) are observed in a series of activities, includ-
ing free play, cleanup, a bubbles sequence, and four puzzle tasks, as well as a separa-

114 | Assessing Infants and Toddlers—Answer Guide

 TABLE 2–1. Observable patterns of emotional development in clinically salient developmental epochs
Domains Birth to 2 months 2–7 months 7–18 months 18–36 months

Social Quiet, alert state evident for Social smiling Stranger wariness Awareness of relationship to
minutes at a time Sustained eye-to-eye contact Separation protest from group
attachment figures More emphasis on personal
Social referencing possessions
Emotional Crying, peaking at 6 weeks Joy, fear, surprise apparent Affective attunement Moral emotions: shame,
cross-culturally and then Greater differentiation of guilt, pride
waning affective states
Communicative Crying indicating distress Responsive cooing Intentional communication; some Expressive language
protowords and some words blossoms
Play Exploratory Parallel play (12–24 months) Early representational play
(24–36 months)
Gross motor Improved tone Rolling over (3–4 months) Walking (12–15 months) Running (1½–2 years);
Sitting independently jumping (2½–3 years)
(6–8 months)
Fine motor Grasping with one hand Pincer grasp (7–9 months); Development of hand
(6 months) transfer of objects from one hand dominance; ability to stack
to the other (12 months) two blocks at 18 months
and eight blocks at
30 months, to scribble
spontaneously, and to
copy a circle (36 months)
Growth Regaining of birth weight by Doubling of birth weight Tripling of birth weight at 1 year Quadrupling of birth weight
2 weeks by 4–6 months at 2 years

Assessing Infants and Toddlers—Answer Guide | 115

 tion and reunion. The procedure provides a standardized method of assessing a
number of domains of the parent–child relationship including reciprocal emotions,
protection and safety, comforting and comfort seeking, teaching and learning, play,
discipline and response to limits, and parental structure and child’s self-regula-
tion (option D is incorrect). (Chapter 2, Assessing Infants and Toddlers/Formal
Assessment Procedures, pp. 26, 28)

2.4 What assessment tool can best provide information about dyadic emotional reg-
ulation for infants ages 3–6 months?

A. Diagnostic Infant Preschool Structured Interview.

B. Early Childhood Screening Assessment.
C. Child Behavior Checklist.
D. Still-face paradigm.

The correct response is option D: Still-face paradigm.

For younger infants (3–6 months), the still-face paradigm can provide valuable in-
formation about dyadic emotional regulation (option D is correct). The procedure
includes three phases: a naturalistic interaction, a 3-minute period when the parent
maintains a nonreactive (“still”) facial expression, and a 3-minute reengagement
period when the parent interacts as usual. Reponses to the still-face procedure cor-
relate with maternal internal representation of the infant (Rosenblum et al. 2002)
and predict future attachment classification.
The Diagnostic Infant Preschool Structured Interview is a respondent-based in-
terview of parents of children ages 18–60 months (Scheeringa and Haslett 2010).
The interview includes symptoms from the Research Diagnostic Criteria: Preschool
Age and DSM-IV. It also explores the degree to which parents have accommo-
dated their children’s behavioral patterns. The interview is intended to provide
an efficient approach to the early childhood diagnostic interview and includes di-
agnostic algorithms in each module (option A is incorrect).
The Child Behavior Checklist (Achenbach and Rescorla 2000) and Early Child-
hood Screening Assessment (Gleason et al. 2010) are caregiver report checklists
for children ages 18–60 months. Parent or child care provider report measures can
be useful ways of assessing the level of reported symptoms. Validated, normed
measures allow comparison of the child’s symptom level with larger populations
(options B and C are incorrect) (Table 2–2). (Chapter 2, Assessing Infants and
Toddlers/Formal Assessment Procedures, pp. 28–31; Table 2–3, p. 31)

2.5 What is the best studied influence on parent report measures?

A. Maternal depression.
B. Child behaviors.
C. Child development.
D. Parental sensitivity.

116 | Assessing Infants and Toddlers—Answer Guide

 TABLE 2–2. Selected measures of early childhood symptoms
Ages, Number Special
Measure months Domains Format of items Validity Reliability characteristics

Ages & Stages 6–60 Self-regulation, 3-point Likert 22–36 Sensitivity in predicting Excellent test- Screening
Questionnaires: compliance, scale a positive score on the retest reliability measure;
Social- communication, Different forms CBCL and Vineland after 1–3 weeks includes
Emotional adaptive func- for each age Social-Emotional Early (r=0.91) strength-based
(Squires et al. tioning, auton- group (months): Childhood Scales, or items; validity
2002)a omy, affect, and 6, 18, 24, 30, 36, a known diagnosis: using broadly
interaction with 48, 60 71%–85% defined criteria
people Specificity: 90%–98%
In children under 18
months, no correlation
with observed infant
interactive behavior;
high correlation with
maternal distress and
psychological symptoms
(Salomonsson and Sleed
2010)
Child Behavior 18–60 Internalizing, 3-point Likert 99 Higher scores in clinically 1-week test-retest Computer scoring
Checklist 1½–5 externalizing, scale referred children than in reliability: system; validated
(Achenbach and and total non–clinically referred mean=0.85 teacher rating
Rescorla 2000)b problems children (effect size=0.3); (parent report), form
77% referred sample vs. 0.81 (teacher
26% report)
Early Childhood 18–60 Internalizing, 3-point Likert 40 (36 child- Sensitivity 86% predicting Test-retest reliabil- Includes parent
Screening externalizing, scale focused, DIPA diagnosis; ity: Spearman’s depression and
Assessment relationship, 4 parent- specificity 83% ρ=0.81 distress items and
(Gleason et al. parent depres- focused) Strong correlations with opportunity to
2010)c sion and distress CBCL and moderate with indicate concern
BITSEA about individual
items

Assessing Infants and Toddlers—Answer Guide | 117

 TABLE 2–2. Selected measures of early childhood symptoms (continued)
Ages, Number Special
Measure months Domains Format of items Validity Reliability characteristics

Infant-Toddler 12–36 Internalizing, 3-point Likert 166 (42 for Correlation with CBCL total Mean 1-month test- Includes strengths;
Social and Emo- externalizing, scale BITSEA) problem scores: r=0.47 retest reliability: BITSEA screener
tional Assess- dysregulation, (internalizing problems); r=0.82–0.90 for (a companion
ment and Brief and competence r=–0.67 (externalizing domains measure) avail-
Infant-Toddler problems) able
Social and Emo- Correlation with observer
tional Assess- ratings r=0.20–0.31
ment (Briggs-
Gowan and Car-
ter 2002)d
Survey of Well- 0–18 BPSC: irritability, 3-point Likert BPSC: 12 BPSC correlates at low- Test-retest Part of larger sys-
being of Young (BPSC), inflexibility, and Scale PPSC: 18 moderate levels with reliability= tem of primary
Children: Baby 18–60 difficulty with ASQ:SE, PHQ-2, and 0.71–0.75 care screening;
Pediatric Symp- months routines difficult child on PSI ease of use, free
tom Checklist (PPSC) PPSC: externaliz- PPSC predicting clinical
and Preschool ing, internalizing, range CBCL scale
Pediatric Symp- attention prob- Sensitivity: 0.75–0.89;
tom Checklist lems, and parent- specificity: 0.77

118 | Assessing Infants and Toddlers—Answer Guide

(Sheldrick et al. ing challenges
2012)e
Note. ASQ:SE=Age & Stages Questionnaires: Social-Emotional; BITSEA=Brief Infant-Toddler Social and Emotional Assessment; BPSC=Baby Pediatric Symptom
Checklist; CBCL=Child Behavior Checklist; DIPA=Diagnostic Interview for the Preschool Age; PHQ-2: Patient Health Questionnaire–2; PPSC=Preschool Pediatric
Symptom Checklist; PSI=Parenting Stress Index.
a
Purchasing information: www.brookespublishing.com/store/books/squires-asqse/index.htm.
bPurchasing information: www.aseba.com.
c
Free download information: http://www.infantinstitute.org/measures-manuals/.
d
Purchasing information: http://pearsonassess.com.
eFree download information: theswyc.org.
 The correct response is option A: Maternal depression.

The best studied influence on parent report measures is maternal depression (op-
tion A is correct). Maternal depression is associated with higher levels of reported
symptoms than concurrent reports by child care providers, but also higher levels
of clinician-observed symptoms in play, especially when mothers have comorbid
psychopathology (Carter et al. 2001; Chilcoat and Breslau 1997; Dawson et al.
2003). Researchers and clinicians postulate that maternal depression may influ-
ence child behaviors within the relationship (option B is incorrect) and child devel-
opment in multiple domains (option C is incorrect), as well as parental sensitivity
to challenging child behaviors (option D is incorrect). (Chapter 2, Assessing In-
fants and Toddlers/Formal Assessment Procedures/Caregiver-Report Checklists,
p. 30)

References
Achenbach T, Rescorla L: Manual for the ASEBA Preschool Form. Burlington, University of Ver-
mont, 2000
Briggs-Gowan M, Carter AS: Brief Infant Toddler Social Emotional Assessment (BITSEA) Manual
Version 2.0. New Haven, CT, Yale University, 2002
Carter AS, Garrity-Rokous FE, Chazan-Cohen R, et al: Maternal depression and comorbidity: pre-
dicting early parenting, attachment security, and toddler social-emotional problems and com-
petencies. J Am Acad Child Adolesc Psychiatry 40(1):18–26, 2001 11195555
Chilcoat HD, Breslau N: Does psychiatric history bias mothers’ reports? An application of a new
analytic approach. J Am Acad Child Adolesc Psychiatry 36(7):971–979, 1997 9204676
Cooper G, Hoffman GT, Powell B: Circle of Security: COS-P facilitator DVD manual 5.0. Spokane,
WA, Marycliff Institute, 2009
Crowell JA, Feldman SS: Mothers’ internal models of relationships and children’s behavioral and
developmental status: a study of mother-child interaction. Child Dev 59(5):1273–1285, 1988
2458891
Dawson G, Ashman SB, Panagiotides H, et al: Preschool outcomes of children of depressed mothers:
role of maternal behavior, contextual risk, and children’s brain activity. Child Dev 74(4):1158–
1175, 2003 12938711
Gleason MM, Zeanah CH, Dickstein S: Recognizing young children in need of mental health as-
sessment: development and preliminary validity of the Early Childhood Screening Assess-
ment. Infant Ment Health J 31(3):335–357, 2010
Oppenheim D, Koren-Karie N: Mothers’ insightfulness regarding their children’s internal worlds:
the capacity underlying secure child-mother relationships. Infant Ment Health J 23(6):593–
605, 2002
Rosenblum KL, McDonough S, Muzik M, et al: Maternal representations of the infant: associations
with infant response to the still face. Child Dev 73(4):999–1015, 2002 12146751
Salomonsson B, Sleed M: The Ages & Stages Questionnaire: Social-Emotional: a validation study
of a mother-report questionnaire on a clinical mother-infant sample. Infant Ment Health J
31(4):412–431, 2010
Scheeringa MS, Haslett N: The reliability and criterion validity of the Diagnostic Infant and Pre-
school Assessment: a new diagnostic instrument for young children. Child Psychiatry Hum
Dev 41(3):299–312, 2010 20052532
Sheldrick RC, Henson BS, Merchant S, et al: The Preschool Pediatric Symptom Checklist (PPSC):
development and initial validation of a new social/emotional screening instrument. Acad Pe-
diatr 12(5):456–467, 2012 22921494

Assessing Infants and Toddlers—Answer Guide | 119

Shonkoff JP, Garner AS, Committee on Psychosocial Aspects of Child and Family Health, et al: The
lifelong effects of early childhood adversity and toxic stress. Pediatrics 129(1):e232–e246, 2012
22201156
Squires J, Bricker D, Twombly ES, et al: Ages & Stages Questionnaires: Social-Emotional. Balti-
more, MD, Paul H Brookes, 2002

120 | Assessing Infants and Toddlers—Answer Guide

 C H A P T E R 3

Assessing the
Preschool-Age Child
3.1 Which of the following represents the ideal format for conducting a comprehen-
sive assessment of a preschool-age child?

A. One session with the child and primary caregiver.

B. Several sessions on different days with the child and with only the primary
caregiver.
C. Several sessions on the same day with the child and with more than one care-
giver whenever possible.
D. Several sessions on different days with the child and with more than one care-
giver whenever possible.

The correct response is option D: Several sessions on different days with the
child and with more than one caregiver whenever possible.

Because of significant state- and relationship-related variation in the mental sta-

tus of the young child, it is necessary to observe a preschooler on more than one
occasion and, ideally, with more than one caregiver. Thus, assessments are best done
over a series of several sessions (option A is incorrect) on different days (option C
is incorrect) and, whenever possible, with different caregivers (option B is incor-
rect; option D is correct). (Chapter 3, Assessing the Preschool-Age Child, p. 38)

3.2 Which types of observations pertaining to the caregiver–child dyad are most in-
formative in the assessment of the preschool-age child?

A. Unstructured (free-play) and semistructured observations.

B. Very structured and structured observations.
C. Structured and semistructured observations.
D. Structured and unstructured (free-play) observations.

The correct response is option A: Unstructured (free-play) and semistructured

observations.

121
 The child’s experience of the first encounter in the clinical setting is important to
set the stage for the evaluation, as well as his or her general feelings and attitudes
about mental health treatment. For this reason, it is important to conduct a free-
play session prior to any structured tasks that may involve minor stressors (op-
tions B, C, and D are incorrect). In subsequent sessions, a semistructured format,
in which the dyad is observed performing specific tasks, provides another useful
method of observation for the preschool assessment (option A is correct). (Chap-
ter 3, Assessing the Preschool-Age Child/Dyadic Play Assessment and Mental
Status Examination, pp. 42–43)

3.3 Which of the following is true regarding mental health disorders in preschool-age
children?

A. Externalizing disorders prompt caregivers to seek care.

B. Anxiety disorders predominate in preschool clinic samples.
C. Preschool diagnoses have been shown to be transient and do not warrant early
intervention.
D. Externalizing disorders are more distressing to the child and family than inter-
nalizing disorders.

The correct response is option A: Externalizing disorders prompt caregivers to

seek care.

Although externalizing disorders (attention-deficit/hyperactivity [ADHD] and op-

positional defiant disorder [ODD]) predominate in the population of preschool-
age children presenting for mental health treatment, a substantial minority of pre-
schoolers present with internalizing disorders, defined as depressive and anxiety
disorders (option B is incorrect). While the disruption of externalizing disorders
prompts caregivers to seek care (option A is correct), the impact of internalizing
symptoms may be even more distressing to the child and family (option D is in-
correct). The assessment of impairment must consider not only the individual
functioning of the child but also the effect of his or her symptoms on the functioning
of the family system (e.g., the mother cannot maintain a job because her preschool
child has been expelled from several day care centers for aggression). Overall, stud-
ies suggest that preschool diagnoses (ODD, ADHD, major depressive disorder)
persist into school age and therefore warrant early intervention (Bufferd et al.
2012; Keenan and Wakschlag 2002; Lahey et al. 2004; Luby et al. 2014) (option C
is incorrect). (Chapter 3, Assessing the Preschool-Age Child, pp. 51–52)

3.4 Which of the following is true about obtaining the comprehensive history of the
preschool-age child?

A. The developmental history does not include milestone achievements in sen-

sory, social, and emotional domains because they are difficult to quantify.
B. Comprehensive history from primary caregivers occurs with the child present
to avoid damaging the rapport with the child.

122 | Assessing the Preschool-Age Child—Answer Guide

 C. Details of pregnancy and perinatal history are essential and often relevant to
the chief complaint and current mental state.
D. Information should be obtained from only one caregiver.

The correct response is option C: Details of pregnancy and perinatal history are
essential and often relevant to the chief complaint and current mental state.

A standard format for a preschool mental health assessment has been established
in the Washington University School of Medicine Infant/Preschool Mental Health
clinic. In the first session, all primary caregivers are asked to come in without the
child to give a comprehensive history. This information is more expediently ob-
tained when the child is not present, and unlike in the assessment of the adoles-
cent, there is little risk of damaging the rapport with the preschool child when
caregivers are interviewed before the child (option B is incorrect). Information
should be obtained from all relevant caregivers. This will ensure a less biased un-
derstanding of the child’s symptomatology and avoid one caregiver assuming the
role as “spokesperson” for the child’s behaviors (option D is incorrect). The devel-
opmental history includes milestone achievement in the following domains: mo-
tor, language, cognitive, sensory, social, and emotional (option A is incorrect).
Details of pregnancy and perinatal history—both medical and psychological—are
essential and are often relevant to the chief complaint and current mental state (op-
tion C is correct). (Chapter 3, Assessing the Preschool-Age Child/Format of a
Preschool Assessment, pp. 38–40)

3.5 Which is the most beneficial approach when giving feedback to parents regarding
the assessment of their preschool-age child?

A. Begin before the parents speak.

B. Avoid addressing any parental resistance.
C. Serve as a collaborator.
D. Ignore any ambivalence displayed by the parent.

The correct response is option C: Serve as a collaborator.

The likelihood of parents’ receptiveness increases the more the clinician approaches
the feedback session in a collaborative manner (option C is correct). Greenspan
(2003) makes a number of suggestions on ways to provide feedback to caregivers:
1) let the parents begin by presenting their concerns (option A is incorrect); 2) focus
on and address any parental resistance (option B is incorrect); 3) serve as a collabora-
tor (option C is correct) by helping parents integrate their earlier perceptions of
their child with one arising from the evaluation; 4) refer to observations of the child
in a developmental context in order to present information in a nonthreatening
way; and 5) acknowledge any ambivalence displayed by the parent (option D is in-
correct). (Chapter 3, Assessing the Preschool-Age Child/Providing Feedback
and Recommendations to Caregivers, p. 44)

Assessing the Preschool-Age Child—Answer Guide | 123

3.6 Which of the following is true regarding use of play in the assessment of the pre-
school-age child?

A. Direct interviewing is the most effective method for assessing the internal emo-
tional state of the preschooler.
B. Observation of the child in play is essential to the mental status examination
of the preschool-age child.
C. If negative play themes emerge, the clinician should intervene to prevent harm.
D. Play is universal and not influenced by variables such as cultural values.

The correct response is option B: Observation of the child in play is essential to

the mental status examination of the preschool-age child.

The clinician must use different strategies to access the internal emotional state of
the preschooler than the direct interview methods used with older children and
adults. Direct approaches may even be counterproductive, causing the child to
become more inhibited (option A is incorrect). Observation of the preschool child
in play is essential because a number of mental status observations can be made
(option B is correct). The clinician’s ability to tolerate negative play themes is crit-
ical. Unless the child is harming himself or herself or others or damaging property,
the clinician should let the child’s play themes unfold without interference (op-
tion C is incorrect). Play is influenced by a number of variables, including cultural
values, family relationships, child-rearing practices, toy familiarity, developmen-
tal expectations, and life experiences (Hwa-Froelich 2004) (option D is incorrect).
(Chapter 3, Assessing the Preschool-Age Child/Accessing the Preschool Child
as Informant in the Process, p. 46; Mental Status Examination of the Preschool
Child, pp. 46–47; Cultural Context of the Preschool Assessment, p. 50)

References
Bufferd SJ, Dougherty LR, Carlson GA, et al: Psychiatric disorders in preschoolers: continuity from
ages 3 to 6. Am J Psychiatry 169(11):1157–1164, 2012 23128922
Greenspan SI: The Clinical Interview of the Child. Washington, DC, American Psychiatric Publish-
ing, 2003
Hwa-Froelich DA: Play assessment for children from culturally and linguistically diverse back-
grounds. Perspectives on Communication Disorders and Sciences in Culturally and Linguis-
tically Diverse Populations 11(2):5–9, 2004
Keenan K, Wakschlag LS: Can a valid diagnosis of disruptive behavior disorder be made in pre-
school children? Am J Psychiatry 159(3):351–358, 2002 11869995
Lahey BB, Peham WE, Loney J, et al: Three-year predictive validity of DSM-IV attention deficit hy-
peractivity disorder in children diagnosed at 4–6 years of age. Am J Psychiatry 161(11):2014–
2020, 2004 15514401
Luby JL, Gaffrey MS, Tillman R, et al: Trajectories of preschool disorders to full DSM depression
at school age and early adolescence: continuity of preschool depression. Am J Psychiatry
171(7):768–776, 2014 24700355

124 | Assessing the Preschool-Age Child—Answer Guide

 C H A P T E R 4

Assessing the
Elementary School–Age
Child
4.1 Which of the following statements is true regarding suicidal thinking and behaviors
in school-age children?

A. Inquiry regarding suicidal thinking and behavior may cause a child to adopt
this thinking and behavior.
B. Suicidal thinking and behaviors do not exist in this age group.
C. It is imperative to evaluate for past and current history of suicidal ideation and
suicide plans/attempts.
D. It is not imperative to evaluate for nonsuicidal self-injurious ideation and be-
haviors.

The correct response is option C: It is imperative to evaluate for past and cur-
rent history of suicidal ideation and suicide plans/attempts.

Suicidal thinking and behaviors do exist in school-age children (option B is incor-

rect). It is therefore imperative to evaluate for past and current history of suicidal
ideation and suicide plans/attempts, as well as nonsuicidal self-injurious ide-
ation and behaviors (Tishler et al. 2007) (option C is correct; option D is incorrect).
Inquiry regarding suicidal thinking and behavior does not cause a child to adopt
this thinking and behavior (Greene 1994) (option A is incorrect). (Chapter 4, As-
sessing the Elementary School–Age Child/Assessment Components, p. 62)

4.2 Which of the following is the best approach for interviewing a school-age child?

A. Ask the child about any history of abuse in the presence of his or her parents.
B. Interview the parent and child together when discussing family history of men-
tal health illness.
C. Meet with the child alone to ask about his or her self-esteem.
D. Ensure that parents get to discuss all issues with the child present.

125
 The correct response is option C: Meet with the child alone to ask about his or
her self-esteem.

It is important to interview the child and parent separately. Certain topics should
be discussed in the absence of the child or the parent. It is critical to ask about pos-
sible abuse privately with the child and with the parents (option A is incorrect).
Children may find it more difficult to discuss abuse in the presence of others, be-
cause of shame, fear of consequences, or guilt. Meeting with the child alone is also
an opportunity to ask the child about his or her self-esteem (option C is correct).
When the clinician is discussing relations between parents, family history of men-
tal illness, and discipline practices, it is best to interview the parent alone (option
B is incorrect). Often parents also welcome the opportunity to expand on other is-
sues in the absence of their child (option D is incorrect). (Chapter 4, Assessing the
Elementary School–Age Child/Assessment Components, p. 63)

4.3 What is the most appropriate step to take if a parent or guardian opts to limit the
gathering of collateral information from a previous provider?

A. Communicate freely with the previous provider anyway, because there is no

need to obtain consent before contacting previous providers.
B. Take no action, because gathering collateral information is not an important
part of a comprehensive evaluation.
C. Take no action, because most parents do not agree to such communication
with previous providers.
D. Honor the parent’s preferences, and perhaps revisit the issue as the working
relationship grows.

The correct response is option D: Honor the parent’s preferences, and perhaps
revisit the issue as the working relationship grows.

It is important to gather information regarding any previous evaluations or psy-

chiatric treatment and the experiences that accompanied that treatment (options
B and C are incorrect). Gathering collateral information both provides a more
comprehensive picture and corrects inaccurate reports. Sharing with other people
will require verbal and written consent to communicate information (option A is
incorrect). Most of the time, people willingly agree to communication with other
pertinent parties (option C is incorrect). However, some parents opt either to limit
communication to specific types of information or to not share any information at
all. These preferences must be honored, and perhaps as the working relationship
grows, they can be revisited (option D is correct). (Chapter 4, Assessing the Ele-
mentary School–Age Child/Assessment Process, pp. 58–59)

4.4 What principles should a clinician consider when speaking to school-age children?

A. A general rule in asking children questions is to use “why” questions.

B. Children’s lack of elaborate responses is indicative of their unwillingness to
speak.

126 | Assessing the Elementary School–Age Child—Answer Guide

 C. School-age children generally do not spontaneously discuss many of the matters
that are important to review during a psychiatric assessment.
D. Offering answer choices is not a good strategy.

The correct response is option C: School-age children generally do not sponta-

neously discuss many of the matters that are important to review during a psy-
chiatric assessment.

When interviewing the school-age child, the clinician must use developmentally
appropriate language and communication skills. School-age children generally
do not spontaneously discuss many of the matters that are important to review
during a psychiatric assessment (option C is correct). Children typically use short
sentences. Children’s lack of elaborate responses is indicative not of their unwill-
ingness to speak, but rather of their tendency to be terse (option B is incorrect). A
general rule of asking children questions is to avoid “why” questions (option A is
incorrect). Asking about cause requires analytical thinking that is beyond many
children’s abilities. Giving choices of response is a good strategy (option D is in-
correct), but with too many choices, children may simply choose the last option
because that is what they remember. When offering choices, the clinician should
allow time for a response after each option. (Chapter 4, Assessing the Elementary
School–Age Child/Speaking With the School-Age Child, pp. 64–65)

4.5 After the clinician has completed a psychiatric evaluation and organized the in-
formation in a biopsychosocial formulation, what is the best way to present the
findings to the family?

A. Concentrate on the psychopathology of the child and family and do not discuss
their strengths.
B. List the symptoms and explain the possible contributing factors.
C. Omit difficult topics such as family relations as contributors.
D. Meet separately with the parent and child.

The correct response is option B: List the symptoms and explain the possible con-
tributing factors.

Once all the information has been gathered, the clinician should present the find-
ings to the family in a direct and neutral manner. Typically, meeting with the child
and parent together is appropriate to present the findings (option D is incorrect). It
is best to present, and often lead with, the strengths of the child and family and,
where appropriate, to highlight domains where psychopathology is absent (option
A is incorrect). When the clinician is discussing the diagnostic conclusions, it is best
not only to list the symptoms but also to explain the possible factors that have con-
tributed to the symptoms (option B is correct). While it is difficult to raise topics
such as family relations as contributors, it is important to do so, as the explanation
can help justify the recommended interventions, such as parental guidance or fam-
ily therapy (option C is incorrect). (Chapter 4, Assessing the Elementary School–
Age Child/Assessment: Formulation and Treatment Planning, pp. 69–70)

Assessing the Elementary School–Age Child—Answer Guide | 127

References
Greene DB: Childhood suicide and myths surrounding it. Soc Work 39(2):230–232, 1994 8153764
Tishler CL, Reiss NS, Rhodes AR: Suicidal behavior in children younger than twelve: a diagnostic
challenge for emergency department personnel. Acad Emerg Med 14(9):810–818, 2007
17726127

128 | Assessing the Elementary School–Age Child—Answer Guide

 C H A P T E R 5

Assessing Adolescents
5.1 Which of the following is an important prerequisite to beginning an assessment of
an adolescent?

A. Rapport building.
B. Data collection.
C. Establishing custody or guardianship.
D. Understanding the adolescent’s interests and strengths.

The correct response is option C: Establishing custody or guardianship.

Establishing custody or guardianship is an important prerequisite to beginning

an assessment (option C is correct). For children, usually the noncustodial parent
has the right to participate in the medical assessment and treatment but not begin
a treatment process unless it is emergent. In the first individual meeting with the
adolescent, the key dialectic on which to focus is between rapport building and
data collection (options A and B are incorrect). The primary focus at the start of the
interview is to begin to understand the adolescent’s interests and strengths (option
D is incorrect). (Chapter 5, Assessing Adolescents, pp. 74; The Adolescent Inter-
view, p. 78)

5.2 What is the proper balance between confidentiality for an adolescent and sufficient
communication with the parent?

A. Everything the adolescent shares will be kept confidential.

B. It is the parent’s right to know every detail that the adolescent shares.
C. An adolescent may assume everything he or she says will be communicated
directly to the parent.
D. The parent should have an overview of problems unless the adolescent would
be at risk of harm.

The correct response is option D: The parent should have an overview of prob-
lems unless the adolescent would be at risk of harm.

Parents should be told the clinician will give them the overview of problems and
diagnoses, without specific details of statements and behaviors reported by the ad-

129
 olescent, unless the adolescent would be at risk of harm if the parents were not in-
formed (option D is correct). However, some teens will assume that everything will
be confidential, causing difficulties when significant issues need to be disclosed to
parents (option A is incorrect). Conversely, parents often think it is their right to
know every detail divulged by the adolescent in the interview because they are bring-
ing their underage child for assessment, and they are paying for it too (option B is
incorrect). If adolescents assume that everything they say will be communicated di-
rectly to the parent, this is likely to block the flow of information (option C is in-
correct). (Chapter 5, Assessing Adolescents/Beginning the Assessment, p. 76)

5.3 What technique should the interviewer use to move forward if the adolescent is not
engaged in the interview?

A. Data collection.
B. Motivational enhancement techniques.
C. Discussing the adolescent’s perception of why he or she has been brought for
evaluation.
D. Closed-ended questions.

The correct response is option B: Motivational enhancement techniques.

Frequently, an adolescent may deny any problems or shrug and say, “I don’t
know,” when asked for ideas about problems. This is often a sign that the adoles-
cent is not yet engaged. The interviewer may have to spend more time in the en-
gagement process, perhaps using some motivational enhancement techniques, in
order to move forward (option B is correct). Motivational interviewing focuses on
the person’s interests, concerns, and goals, and thus likely provides the adoles-
cent with a more positive experience. In the first individual meeting with the ad-
olescent, the key dialectic on which to focus is between rapport building and data
collection. Both need to be accomplished. However, excessive focus on data collec-
tion can impede rapport building (option A is incorrect). After initial rapport build-
ing, the discussion of the adolescent’s perception of why he or she has been brought
for evaluation can proceed (option C is incorrect). The interviewer should begin
the interview with open-ended questions in order to obtain as broad and com-
plete an idea as possible about the adolescent’s views (option D is incorrect). (Chap-
ter 5, Assessing Adolescents/The Adolescent Interview, pp. 78–79)

5.4 Which aspect of family functioning includes the elements of adaptability and de-
gree of cohesion among members of the family?

A. Family communication.
B. Family beliefs.
C. Family structure.
D. Family regulatory processes.

The correct response is option C: Family structure.

130 | Assessing Adolescents—Answer Guide

 Family structure refers to the important relationships and boundaries within fam-
ilies and the transactional patterns that exist within these relationships (Minuchin
1974). Elements of family structure include the family’s ability to change and adapt
to new circumstances (adaptability) and the degree of cohesion among the mem-
bers of the family (option C is correct). Family communication refers to the ability
to communicate facts and emotional content as well as the ability to problem
solve (option A is incorrect). Family beliefs are ideas about reality that are shared
among family members and denote a kind of family memory system (Josephson
and AACAP Work Group on Quality Issues 2007) (option B is incorrect). Family
regulatory processes refers to the ability of the family to meet the developmental
needs of the children (option D is incorrect). (Chapter 5, Assessing Adolescents/
Family Assessment, p. 83)

5.5 What is the first aspect of focus when presenting the findings of an adolescent as-
sessment to the family?

A. The strengths of both the adolescent and the parents.

B. The problems areas uncovered during the assessment.
C. A formulation of how the problems developed and are perpetuated.
D. The proposed plan for treatment.

The correct response is option A: The strengths of both the adolescent and the
parents.

The first part of the presentation should always focus on the strengths of both the
adolescent and the parents (option A is correct). Beginning this way helps to set
everyone at ease. Next, the clinician begins to discuss the problem areas uncov-
ered during the assessment (option B is incorrect). It is important to convey not
only what symptoms and diagnoses have been found but also a formulation of
how the problems developed and are perpetuated (option C is incorrect). Finally,
the clinician discusses the proposed plan for treatment and prognosis (option D
is incorrect). (Chapter 5, Assessing Adolescents/Presenting the Findings, p. 85)

References
Josephson AM, AACAP Work Group on Quality Issues: Practice parameter for the assessment of
the family. J Am Acad Child Adolesc Psychiatry 46(7):922–937, 2007 17581454
Minuchin S: Families and Family Therapy. Cambridge, MA, Harvard University Press, 1974

Assessing Adolescents—Answer Guide | 131

 C H A P T E R 6

Neurological Examination,
Electroencephalography,
Neuroimaging, and
Neuropsychological Testing
6.1 Which part of the neurological examination is least objective in nonverbal and/or
young patients?

A. Gait.
B. Motor examination.
C. Sensory examination.
D. Cranial nerve assessment.

The correct response is option C: Sensory examination.

A significant proportion of the neurological examination can be obtained by sim-

ply observing and speaking with the child or adolescent. The sensory examin-
ation can be challenging and is the least objective part of the examination in
nonverbal and/or young patients (option C is correct). Gait should be assessed in
all patients. The examiner should note whether there is any asymmetry, and
whether there are any associated unusual movements. These abnormalities can
often be accentuated during running (option A is incorrect). The motor examina-
tion typically consists of assessment of muscle tone and strength. Having the pa-
tient perform different tasks will give at a minimum an idea of how the muscles
oppose gravity and whether the patient can withstand the resistance of his or her
own body (option B is incorrect). Cranial nerve assessment is easily observed
during the interview (option D is incorrect). (Chapter 6, Neurological Examina-
tion, Electroencephalography, Neuroimaging, and Neuropsychological Test-
ing/ The Neurological Examination/General Guidelines and Developmental
Aspects, pp. 90–91)

133
6.2 Which of the following is part of coordination assessment?

A. Observing the patient’s sitting posture.

B. Having the patient walk on an imaginary tightrope.
C. Measuring the patient’s height, weight, and head circumference.
D. Having the patient chew and swallow.

The correct response is option B: Having the patient walk on an imaginary tightrope.

Coordination assessment may be accomplished by having the patient walk on an

imaginary tightrope to assess tandem gait (option B is correct). Observing the pa-
tient’s sitting posture is part of the motor examination (option A is incorrect).
Measuring the patient’s height, weight, and head circumference is a part of the
general physical examination (option C is incorrect). For a patient with suspected
weakness in the oral or facial muscles, observing the patient chew or swallow is
helpful and is part of the cranial nerve assessment (Table 6–1) (option D is incor-
rect). (Chapter 6, Neurological Examination, Electroencephalography, Neuro-
imaging, and Neuropsychological Testing/The Neurological Examination/
General Guidelines and Developmental Aspects, pp. 90–92; Table 6–1, p. 91)

6.3 What is the finding or findings for a lower motor neuron lesion?

A. Spastic paralysis.
B. Muscle hypertonia.
C. Babinski reflex positive.
D. Muscle fasciculations and fibrillations.

The correct response is option D: Muscle fasciculations and fibrillations.

Muscle fasciculations and fibrillations are consistent with a lower motor neuron
lesion (option D is correct). Upper motor neuron lesions are associated with spas-
tic paralysis (option A is incorrect), muscle hypertonia (option B is incorrect), and
presence of a Babinski reflex (Table 6–2) (option C is incorrect). (Chapter 6, Neu-
rological Examination, Electroencephalography, Neuroimaging, and Neuro-
psychological Testing/The Neurological Examination/General Guidelines and
Developmental Aspects, Table 6–2, p. 92)

6.4 Which of the following electroencephalographic (EEG) findings is indicative of

seizure activity in a school-age child?

A. Alpha wave pattern.

B. High-amplitude slowing.
C. Theta wave pattern.
D. Spike and slow-wave discharge.

The correct response is option D: Spike and slow-wave discharge.

134 | Neurological Examination, EEG, and Neuroimaging—Answer Guide

TABLE 6–1. Elements of the neurological examination based on observation
Examination
component Observation questions

Mental status • How engaged and oriented is the patient to the environment, people,
and presenting concern?
• Is he or she able to articulate and speak coherently and understand
language?
• Does the speech have regular rate and prosody?
• What is the mood and affect of the patient? Does he or she make good
eye contact?
• Does the patient pay attention and show age-appropriate fund of
knowledge?
Cranial nerves • Is the face symmetric with a good range of facial expression?
• Is there any eyelid or facial drooping?
Motor • What is the sitting posture of the patient?
• Are there any gross or fine movement abnormalities, asymmetry?
• Can he or she get up and down from the chair without using the
armrests (i.e., good proximal muscle strength)?
Sensory • Does the patient have a high-stepping gait, sometimes seen in sensory
neuropathies (Friedrich’s ataxia, vitamin B12 deficiency)?
Cerebellar • Are there any tremors, ataxia, or clumsiness?
Gait • Is there any toe walking (a potential sign of lower-extremity spasticity)
or asymmetry of arm swing while walking (a potential sign of mild limb
paresis)?

Spike and slow-wave discharges induced by either hyperventilation or photic

stimulation are pathological and represent an increased possibility of seizures
(option D is correct). Alpha is the predominant wave pattern while one is awake
with the eyes closed, best seen in the posterior head leads (option A is incorrect).
High-amplitude slowing in school-age children is a normal phenomenon (option
B is incorrect). Theta waves can be seen during awake states in children, although
they are more common in drowsy states (option C is incorrect). (Chapter 6, Neu-
rological Examination, Electroencephalography, Neuroimaging, and Neuro-
psychological Testing/Electroencephalography, p. 93)

6.5 What kind of neuroimaging is used to preoperatively evaluate patients with epi-
lepsy to determine hemispheric language dominance and for surgical planning?

A. Functional magnetic resonance imaging (fMRI).

B. Computed tomography (CT).
C. Magnetic resonance spectroscopy (MRS).
D. Positron emission tomography (PET).

The correct response is option A: Functional magnetic resonance imaging (fMRI).

Clinically, fMRI is most commonly used to preoperatively evaluate patients with

epilepsy to determine hemispheric language dominance and for surgical plan-

Neurological Examination, EEG, and Neuroimaging—Answer Guide | 135

TABLE 6–2. Localization of weakness
Upper motor neuron Lower motor neuron

Character of Spastic paralysis with muscle hypertonia Flaccid paralysis with

weakness hypotonia
Mental status Encephalopathy, developmental delay, Generally preserved
intellectual disability, and seizures
Distribution Asymmetric if due to cortical lesion Usually bilateral
DTRs Increased Decreased or absent
Other findings Babinski reflex positive Babinski reflex not present
Muscle fasciculations and
fibrillations
Note. DTR=deep tendon reflex.

ning (option A is correct). The main indications for CT of the brain are urgent eval-
uations of central nervous system (CNS) trauma, acute brain hemorrhage, and
increased intracranial pressure, or when magnetic resonance imaging (MRI) is not
available or is contraindicated (option B is incorrect). MRS is used for the assess-
ment of metabolic, mitochondrial, and neurodegenerative disorders; identifica-
tion of epileptic focus; and preoperative evaluation of brain tumors (Wycliffe et
al. 2006). MRS has also been extensively used as a research tool in attention-deficit/
hyperactivity disorder and mood and anxiety disorders (option C is incorrect).
Clinically, PET is most useful in identification of focal epileptogenic brain regions
in patients with seizures and with or without structural MRI or EEG abnormali-
ties. Ethical considerations of patient exposure to radiation have limited use of PET
in clinical child psychiatry (option D is incorrect). (Chapter 6, Neurological Exam-
ination, Electroencephalography, Neuroimaging, and Neuropsychological Test-
ing/Neuroimaging, pp. 95–96)

6.6 Which brain area is the last one to mature?

A. Somatosensory cortex.
B. Prefrontal cortex.
C. Visual cortex.
D. Temporal cortex.

The correct response is option B: Prefrontal cortex.

Different brain structures mature at different times (Thompson et al. 2005). Phylo-
genetically older brain areas, such as the olfactory, visual, or somatosensory cortex,
appear to mature first (options A and C are incorrect), followed by the temporal
(option D is incorrect), parietal, and finally prefrontal cortex (option B is correct)
(Casey et al. 2000; Gogtay et al. 2004). (Chapter 6, Neurological Examination,
Electroencephalography, Neuroimaging, and Neuropsychological Testing/
Neuroimaging/Neuroimaging of Brain Development, p. 97)

136 | Neurological Examination, EEG, and Neuroimaging—Answer Guide

6.7 Which of the following is an indication for neuropsychological testing?

A. To examine the emotional basis of functional complaints (e.g., poor memory).

B. To assess unstable mental status.
C. To assess prognosis in functioning in relation to treatment.
D. To assess a patient with an uncontrolled treatable psychiatric disorder.

The correct response is option C: To assess prognosis in functioning in relation

to treatment.

An indication for neuropsychological testing is to assess prognosis for deterioration

or improvement in functioning in relation to treatment (e.g., epilepsy surgery)
(option C is correct). Neuropsychological testing is contraindicated in an acutely
ill patient with unstable mental status or an uncontrolled (but treatable) psychiat-
ric disorder (options B and D are incorrect). Neuropsychological testing examines
the cognitive (not emotional) basis of functional complaints (e.g., poor memory)
(option A is incorrect). (Chapter 6, Neurological Examination, Electroencepha-
lography, Neuroimaging, and Neuropsychological Testing/Neuropsychologi-
cal Testing, p. 99)

6.8 What abnormal electroencephalographic pattern correlates with encephalopathic

states?

A. Spikes.
B. Alpha waves.
C. Global suppression.
D. Beta waves.

The correct response is option C: Global suppression.

Abnormal electroencephalographic patterns, such as generalized slowing or global

suppression, often correlate with encephalopathic states (option C is correct). Spe-
cific electroencephalographic discharges, such as spikes, suggest an epileptogenic
process (option A is incorrect). Alpha is the predominant wave pattern while one
is awake with the eyes closed, best seen in the posterior head leads (option B is
incorrect). Beta waves can be seen during sleep states, particularly in infants and
children, and also in patients receiving medications such as benzodiazepines (op-
tion D is incorrect). (Chapter 6, Neurological Examination, Electroencephalog-
raphy, Neuroimaging, and Neuropsychological Testing, pp. 93, 100)

References
Casey BJ, Giedd JN, Thomas KM: Structural and functional brain development and its relation to
cognitive development. Biol Psychol 54(1–3):241–257, 2000 11035225
Gogtay N, Giedd JN, Lusk L, et al: Dynamic mapping of human cortical development during
childhood through early adulthood. Proc Natl Acad Sci USA 101(21):8174–8179, 2004
15148381

Neurological Examination, EEG, and Neuroimaging—Answer Guide | 137

Thompson PM, Sowell ER, Gogtay N, et al: Structural MRI and brain development. Int Rev Neu-
robiol 67:285–323, 2005 16291026
Wycliffe ND, Thompson JR, Holshouser BA, et al: Pediatric Neuroimaging in Pediatric Neurology:
Principles and Practice, 4th Edition. Edited by Swaiman KF, Ashwal S, Ferriero DM. Philadel-
phia, PA, Mosby Elsevier, 2006

138 | Neurological Examination, EEG, and Neuroimaging—Answer Guide

 C H A P T E R 7

Intellectual Disability
7.1 What is the strongest basis for determining the level of severity of a patient’s in-
tellectual disability?

A. Severity levels are determined by the underlying congenital syndrome leading

to intellectual disability.
B. Severity levels are determined by adaptive functioning.
C. Severity levels are determined by intelligence quotient (IQ).
D. Severity levels are determined by language abilities.

The correct response is option B: Severity levels are determined by adaptive

functioning.

Among other revisions reflected in DSM-5 (American Psychiatric Association

2013), severity levels are now classified by adaptive functioning rather than IQ
(option B is correct; option C is incorrect), and IQ criteria are based on approxi-
mate rather than absolute cutoffs (e.g., 65–75 rather than 70). Adaptive functioning
includes abilities in three domains: conceptual, which refers to language, reading,
writing, math, reasoning, knowledge, and memory; social, as in empathy, social
judgment, interpersonal communication skills, and the ability to follow rules and
to make and retain friendships; and practical, or self-management in areas such as
personal care, job responsibilities, money management, recreation, and organiz-
ing school and work tasks. Thus, language abilities are considered part of adap-
tive functioning (option D is incorrect). Within each syndrome much variation in
terms of intellectual disability severity, attention and cognitive function, and psy-
chiatric and behavioral patterns exists between individuals (option A is incorrect).
(Chapter 7, Intellectual Disability, p. 105; Congenital Syndromes and Neurobe-
havioral Phenotypes, p. 116)

7.2 Which of the following is the correct diagnosis for someone who becomes cogni-
tively disabled after age 18 years?

A. Intellectual disability.
B. Learning disorder.
C. Dementia.
D. Mental retardation.

139
 The correct response is option C: Dementia.

In May 2013, with the publication of DSM-5, the term intellectual disability re-
placed mental retardation for the first time in DSM, and the language used to define
intellectual disability became more closely aligned with that of the American As-
sociation on Intellectual and Developmental Disabilities (AAIDD) (option D is in-
correct). Currently, as in DSM, the AAIDD defines intellectual disability by
significant limitations in intellectual functioning and adaptive behavior, which
include conceptual, social, and practical skills and origination prior to age 18 (op-
tion A is incorrect). Neurocognitive disorders are differentiated from intellectual
disability by a loss of cognitive function. When the onset of intellectual disability
occurs after a period of normal functioning or after age 18 years, the diagnosis is
often dementia (option C is correct). Major neurocognitive disorder can co-occur
with intellectual disability, and in these cases both diagnoses may be given. For
example, in trisomy 21 (Down syndrome), it is common for individuals to de-
velop dementia. Learning and communication disorders are diagnosed when
there is impairment in a specific communication and/or learning domain but not
general impairment in intellectual and adaptive functioning (option B is incor-
rect). (Chapter 7, Intellectual Disability, pp. 105–107; Table 7–1)

7.3 What is the most common form of intellectual disability that the clinician will en-
counter in practice?

A. Mild.
B. Moderate.
C. Severe.
D. Profound.

The correct response is option A: Mild.

Individuals with mild intellectual disability represent 85% of those with intellec-
tual disabilities (option A is correct), and they will show difficulties in learning ac-
ademic skills involving reading, writing, arithmetic, time, or money. In adults,
abstract thinking, executive function, and short-term memory, as well as functional
use of academic skills, are impaired. Compared with typically developing age-
mates, individuals with mild intellectual disability are immature in social interac-
tions. Individuals with moderate intellectual disability represent 10% of individ-
uals with intellectual disability (option B is incorrect), and their conceptual skills
lag markedly behind those of peers. For adults, academic skill development is
typically at an elementary level. Social judgment and decision-making abilities are
limited. Individuals with severe and profound intellectual disability represent 5%
and <1% of cases, respectively (options C and D are incorrect). In these individu-
als, speech may be single words or phrases, and the individual requires support for
all activities of daily living (Table 7–1). (Chapter 7, Intellectual Disability/Defi-
nition, Clinical Description, and Diagnosis/Table 7–1, pp. 107–110)

140 | Intellectual Disability—Answer Guide

 TABLE 7–1. Summary of DSM-5 diagnostic criteria and severity classifications for intellectual disability
DIAGNOSTIC CRITERIA
A. Intellectual function B. Adaptive function C. Onset
Deficits in intellectual function, such as reasoning, prob- Deficits in adaptive functioning that result in failure to meet Onset of intellectual and
lem solving, planning, abstract thinking, judgment, ac- developmental and sociocultural standards for personal adaptive deficits during
ademic learning, and learning from experience, independence and social responsibility. Without ongoing the developmental
confirmed by both clinical assessment and individual- support, the adaptive deficits limit functioning in one or period.
ized, standardized intelligence testing. more activities of daily life, such as communication, social
participation, and independent living across multiple
environments, such as home, school, work, and community.
SEVERITY
Severity level
(% children) Conceptual domain Social domain Practical domain
Mild (85%) For preschool children, there may be Compared with typically developing The individual may function age-
no obvious conceptual differences. age-mates, the individual is appropriately in personal care.The
For school-age children and adults, immature in social interactions. For individual needs some support with
there are difficulties in learning example, there may be difficulty in complex daily living tasks in comparison to
academic skills involving reading, accurately perceiving peers’ social peers. In adulthood, supports typically
writing, arithmetic, time, or money, cues. Communication, involve grocery shopping, transportation,
with support needed in one or conversation, and language are home and child-care organizing, nutritious
more areas to meet age-related more concrete or immature than food preparation, and banking and money
expectations. In adults, abstract expected for age. There may be management. Recreational skills resemble
thinking, executive function (i.e., difficulties regulating emotion and those of age-mates, although judgment
planning, strategizing, priority behavior in age-appropriate related to well-being and organization
setting, and cognitive flexibility), and fashion; these difficulties are noticed around recreation requires support. In
short-term memory, as well as by peers in social situations. There is adulthood, competitive employment is often
functional use of academic skills (e.g., limited understanding of risk in seen in jobs that do not emphasize conceptual
reading, money management), are social situations; social judgment is skills. The individual generally needs
impaired. There is a somewhat immature for age, and the person is support to make health care and legal
concrete approach to problems and at risk of being manipulated by decisions, and to learn to perform a skilled
solutions compared with age-mates. others (gullibility). vocation competently. Support is typically

Intellectual Disability—Answer Guide | 141

needed to raise a family.
 TABLE 7–1. Summary of DSM-5 diagnostic criteria and severity classifications for intellectual disability (continued)
SEVERITY (continued)
Severity level
(% children) Conceptual domain Social domain Practical domain
Moderate (10%) All through development, the The individual shows marked The individual can care for personal needs
individual’s conceptual skills lag differences from peers in social and involving eating, dressing, elimination,
markedly behind those of peers. communicative behavior across and hygiene as an adult, although an
For preschoolers, language and development. Spoken language is extended period of teaching and time
pre-academic skills develop slowly. typically a primary tool for social is needed for the individual to become
For school-age children, progress in communication but is much less independent in these areas, and
reading, writing, mathematics, and complex than that of peers. Capacity reminders may be needed. Similarly,
understanding of time and money for relationships is evident in ties to participation in all household tasks can
occurs slowly across the school years family and friends, and the be achieved by adulthood, although
and is markedly limited compared individual may have successful extended teaching and ongoing supports
with that of peers. For adults, friendships and sometimes for adult-level performance are needed.
academic skill development is romantic relations in adulthood. Independent employment in jobs that

142 | Intellectual Disability—Answer Guide

typically at an elementary level, and However, the individual may not require limited conceptual and
support is required for all use of perceive or interpret social cues communication skills can be achieved,
academic skills in work and personal accurately. Social judgment and but considerable support from co-
life. Ongoing assistance on a daily decision-making abilities are workers and others is needed to manage
basis is needed to complete limited, and caretakers must assist social expectations, job complexities,
conceptual tasks of day-to-day life, with life decisions. Friendships with and responsibilities such as scheduling,
and others may take over these typically developing peers are often transportation, health benefits, and
responsibilities fully for the affected by communication or social money management. A variety of
individual. limitations. Significant social and recreational skills can be developed
communicative support is needed but require supports and learning
in work settings for success. opportunities over an extended period.
Maladaptive behavior is present in a
significant minority and causes social
problems.
 TABLE 7–1. Summary of DSM-5 diagnostic criteria and severity classifications for intellectual disability (continued)
SEVERITY (continued)
Severity level
(% children) Conceptual domain Social domain Practical domain
Severe (5%) Attainment of conceptual skills is Spoken language is quite limited in The individual requires support for all
limited. The individual generally vocabulary and grammar. Speech activities of daily living (e.g., meals,
has little understanding of written may be single words or phrases dressing, bathing, and elimination),
language or of concepts involving and may be supplemented through requires supervision at all times, and
numbers, quantity, time, and money. augmentative means. Communica- cannot make responsible decisions
Caretakers provide extensive tion is focused on the here and now. regarding well-being of self or others.
supports for problem solving Language is used for social commu- In adulthood, tasks at home, recreation,
throughout life. nication more than explication. The and work require ongoing support/
individual understands simple assistance. Skill acquisition in all domains
speech/gestures. Relationships involves long-term teaching and support.
with familiar others are a source Maladaptive behavior, including self-
of pleasure and help. injury, is present in a significant minority.

Intellectual Disability—Answer Guide | 143

 TABLE 7–1. Summary of DSM-5 diagnostic criteria and severity classifications for intellectual disability (continued)
SEVERITY (continued)
Severity level
(% children) Conceptual domain Social domain Practical domain
Profound (<1%) Conceptual skills generally involve the The individual has very limited The individual is dependent on others for all
physical world rather than symbolic understanding of symbolic aspects of daily physical care, health, and
processes. The individual may use communication in speech or safety, although he or she may participate
objects in goal-directed fashion for gesture. He or she may understand in some of these activities as well. Individ-
self-care, work, and recreation. Certain some simple instructions or uals without severe physical impairments
visuospatial skills, such as matching gestures. The individual expresses may assist with daily work tasks at home,
and sorting based on physical charac- his or her own desires and emotions like carrying dishes to the table. Simple ac-
teristics, may be acquired. However, largely through nonverbal, tions with objects may be the basis of par-
motor and sensory impairments may nonsymbolic communication. The ticipation in some vocational activities with
prevent functional use of objects. individual enjoys relationships with high levels of support. Recreational activi-
familiar others, and initiates and ties may involve music, movies, walks, or
responds to social interactions participating in water activities, all with

144 | Intellectual Disability—Answer Guide

through gestural and emotional support. Physical and sensory impairments
cues. Sensory and physical are frequent barriers to home, recreational,
impairments may prevent many and vocational activities. Maladaptive be-
social activities. havior is present in a significant minority.
7.4 What is the strongest predictor for intellectual disability of unknown etiology?

A. Low birth weight.

B. Gender.
C. Socioeconomic status.
D. Multiple births (twins).

The correct response is option A: Low birth weight.

Risk factors for intellectual disability of unknown etiology continue to be studied.

Croen et al. (2001) examined infant and maternal characteristics of more than
11,000 children with intellectual disability of unknown cause. Findings showed
that low birth weight was the strongest predictor of disability (option A is cor-
rect), with systemic inflammation adding considerably to the risk associated with
low birth weight (Leviton et al. 2013). Males; children born to black, Asian, and
Hispanic women and older women; lower level of maternal education; lower so-
cioeconomic status; multiple births; and second- or later-born children are all risk
factors (options B, C, and D are incorrect). (Chapter 7, Intellectual Disability/
Etiology, Mechanisms, and Risk Factors, p. 115)

7.5 Which of the following characteristics most closely describe an individual with
fetal alcohol spectrum disorder?

A. Intellectual disability, tremor/ataxia syndrome, increased risk for psychopa-

thology, and autistic features.
B. Intellectual disability, muscle hypotonia, short stature, distinctive facial ap-
pearance, and obesity.
C. Intellectual disability, seizures, motor stereotypies, breathing abnormalities,
ataxia, and growth failure.
D. Intellectual disability, facial anomalies, prenatal and/or postnatal growth re-
tardation, learning deficits, and attention problems.

The correct response is option D: Intellectual disability, facial anomalies, prenatal

and/or postnatal growth retardation, learning deficits, and attention problems.

Intellectual disability is a hallmark of fetal alcohol spectrum disorder (FASD).

Other symptoms include a distinct pattern of facial anomalies, prenatal and/or
postnatal growth retardation, and cognitive and behavioral abnormalities that in-
clude verbal and nonverbal learning deficits and attention problems (option D is
correct). Fragile X syndrome (described in option A) is a leading cause of intellec-
tual disability that involves complex changes in the X-linked gene FMR1. Full or
loss-of-function mutations cause fragile X syndrome, whereas permutation status
in males (and some females) may cause fragile X–associated tremor/ataxia syn-
drome (FXTAS) (late-onset progressive cerebellar ataxia and tremor). As many as
25% of individuals with fragile X syndrome also have symptoms that meet the cri-
teria for autism spectrum disorder. Fragile X syndrome is characterized by in-

Intellectual Disability—Answer Guide | 145

 creased risk of psychopathology. Down syndrome, or trisomy 21 (described in
option B), is the most common genetic cause of intellectual disability. The pheno-
type is characterized by muscle hypotonia, short stature, and a distinctive facial
appearance; physical findings may include obesity. Rett syndrome (described in
option C) is one of the most common causes of severe intellectual disability in fe-
males. Rett syndrome is associated with a distinctive “regressive” presentation in
which there is a loss of intellectual functioning and fine and gross motor skills, the
development of stereotypic hand-wringing movements and possible breathing
abnormalities, and ataxia. Seizures are present in 90% of cases. Growth failure is
common. (Chapter 7, Intellectual Disability/Congenital Syndromes and Neuro-
behavioral Phenotypes, pp. 118–120)

7.6 What are the current recommendations for genetic testing in individuals with in-
tellectual disability without a definite diagnosis?

A. Genetic testing is recommended regardless of whether dysmorphology, family

history, or other clinical features are present.
B. Genetic testing is recommended if dysmorphology is present.
C. Genetic testing is recommended if there is a strong family history or clinical
features are suggestive of a genetic syndrome.
D. Genetic testing is recommended if either a family history or dysmorphology
is present.

The correct response is option A: Genetic testing is recommended regardless of

whether dysmorphology, family history, or other clinical features are present.

The American College of Medical Genetics recommends standard cytogenetic

analysis at a minimum of a 550-band level for individuals with intellectual dis-
ability without a definite diagnosis regardless of whether dysmorphology, a fam-
ily history, or other clinical features are present (option A is correct; options B, C,
and D are incorrect). (Chapter 7, Intellectual Disability/Evaluation/Cytogenetic
Diagnostic Testing, p. 122)

References
American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 5th Edi-
tion. Arlington, VA, American Psychiatric Association, 2013
Croen LA, Grether JK, Selvin S: The epidemiology of mental retardation of unknown cause. Pedi-
atrics 107(6):E86, 2001 11389284
Leviton A, Fichorova RN, O’Shea TM, et al: Two-hit model of brain damage in the very preterm
newborn: small for gestational age and postnatal systemic inflammation. Pediatr Res
73(3):362–370, 2013 23364171

146 | Intellectual Disability—Answer Guide

 C H A P T E R 8

Autism Spectrum Disorders

8.1 What is the outcome of having DSM-5 consolidate multiple prior diagnoses (e.g.,
Asperger’s disorder and pervasive developmental disorder not otherwise speci-
fied [PDD-NOS]) under the single umbrella term autism spectrum disorder (ASD)?

A. Children with PDD-NOS are typically not eligible to meet ASD criteria.
B. There is a loss of specificity and reliability in diagnosis.
C. There is an emphasis on ASD as a continuum.
D. Social (pragmatic) communication disorder is included under the new ASD cri-
teria as well.

The correct response is option C: There is an emphasis on ASD as a continuum.

In the interest of emphasizing that ASD is a continuum (option C is correct), the

categories of Asperger’s disorder and PDD-NOS, which were listed under the cat-
egory of pervasive developmental disorder in DSM-IV (American Psychiatric As-
sociation 1994), were considered too nonspecific (option B is incorrect) and have
been eliminated in DSM-5 (American Psychiatric Association 2013). A study con-
trasting the DSM-IV and DSM-5 criteria concluded that most children with a
PDD-NOS diagnosis would remain eligible for an ASD diagnosis (Huerta and
Lord 2012) (option A is incorrect). In fact, DSM-5 criteria for ASD include a note
that individuals with a well-established DSM-IV diagnosis of autistic disorder,
Asperger’s disorder, or PDD-NOS should be given the diagnosis of autism spec-
trum disorder (Table 8–1). Reliability of the discrimination among DSM-IV sub-
types was poor, even by experts (option B is incorrect). In DSM-5 there is a new
diagnostic category within the chapter “Neurodevelopmental Disorders” called
social (pragmatic) communication disorder, which is similar to ASD, except for the ab-
sence of restrictive and repetitive behaviors (Table 8–1) (option D is incorrect).
(Chapter 8, Autism Spectrum Disorders/Definition, Clinical Description, and
Diagnosis/Definition of Autism Spectrum Disorder, pp. 136–138; Box 8–1, p. 137)

147
TABLE 8–1. DSM-5 Diagnostic Criteria for Autism Spectrum Disorder

A. Persistent deficits in social communication and social interaction across multiple contexts,
as manifested by the following, currently or by history (examples are illustrative, not ex-
haustive; see text):
1. Deficits in social-emotional reciprocity, ranging, for example, from abnormal social ap-
proach and failure of normal back-and-forth conversation; to reduced sharing of inter-
ests, emotions, or affect; to failure to initiate or respond to social interactions.
2. Deficits in nonverbal communicative behaviors used for social interaction, ranging, for
example, from poorly integrated verbal and nonverbal communication; to abnormali-
ties in eye contact and body language or deficits in understanding and use of gestures;
to a total lack of facial expressions and nonverbal communication.
3. Deficits in developing, maintaining, and understanding relationships, ranging, for exam-
ple, from difficulties adjusting behavior to suit various social contexts; to difficulties in
sharing imaginative play or in making friends; to absence of interest in peers.
Specify current severity:
Severity is based on social communication impairments and restricted, repeti-
tive patterns of behavior (see Table 2 [DSM-5, p. 52]).
B. Restricted, repetitive patterns of behavior, interests, or activities, as manifested by at least two
of the following, currently or by history (examples are illustrative, not exhaustive; see text):
1. Stereotyped or repetitive motor movements, use of objects, or speech (e.g., simple mo-
tor stereotypies, lining up toys or flipping objects, echolalia, idiosyncratic phrases).
2. Insistence on sameness, inflexible adherence to routines, or ritualized patterns of ver-
bal or nonverbal behavior (e.g., extreme distress at small changes, difficulties with
transitions, rigid thinking patterns, greeting rituals, need to take same route or eat
same food every day).
3. Highly restricted, fixated interests that are abnormal in intensity or focus (e.g., strong
attachment to or preoccupation with unusual objects, excessively circumscribed or
perseverative interests).
4. Hyper- or hyporeactivity to sensory input or unusual interest in sensory aspects of the
environment (e.g., apparent indifference to pain/temperature, adverse response to
specific sounds or textures, excessive smelling or touching of objects, visual fascina-
tion with lights or movement).
Specify current severity:
Severity is based on social communication impairments and restricted, repeti-
tive patterns of behavior (see Table 2 [DSM-5, p. 52]).
C. Symptoms must be present in the early developmental period (but may not become fully
manifest until social demands exceed limited capacities, or may be masked by learned
strategies in later life).
D. Symptoms cause clinically significant impairment in social, occupational, or other import-
ant areas of current functioning.
E. These disturbances are not better explained by intellectual disability (intellectual develop-
mental disorder) or global developmental delay. Intellectual disability and autism spectrum
disorder frequently co-occur; to make comorbid diagnoses of autism spectrum disorder
and intellectual disability, social communication should be below that expected for gen-
eral developmental level.

148 | Autism Spectrum Disorders—Answer Guide

Note: Individuals with a well-established DSM-IV diagnosis of autistic disorder, Asperg-
er’s disorder, or pervasive developmental disorder not otherwise specified should be giv-
en the diagnosis of autism spectrum disorder. Individuals who have marked deficits in
social communication, but whose symptoms do not otherwise meet criteria for autism
spectrum disorder, should be evaluated for social (pragmatic) communication disorder.
Specify if:
With or without accompanying intellectual impairment
With or without accompanying language impairment
Associated with a known medical or genetic condition or environmental factor
(Coding note: Use additional code to identify the associated medical or genetic con-
dition.)
Associated with another neurodevelopmental, mental, or behavioral disorder
(Coding note: Use additional code[s] to identify the associated neurodevelopmental,
mental, or behavioral disorder[s].)
With catatonia (refer to the criteria for catatonia associated with another mental disorder,
[DSM-5] pp. 119–120, for definition) (Coding note: Use additional code 293.89 [F06.1]
catatonia associated with autism spectrum disorder to indicate the presence of the comor-
bid catatonia.)

Source. Reprinted from American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders,
5th Edition. Arlington, VA, American Psychiatric Association, 2013. Copyright © 2013 American Psychiatric
Association. Used with permission.

8.2 Which of the following clinical scenarios is most likely to prompt parents’ concern
about delays in their child’s development?

A. The child is not using facial expressions or gestures or showing enthusiasm

when greeting others.
B. The child is not standing by 15 months.
C. The child is not making meaningful eye contact or directing another person’s
attention to things.
D. The child is not using words by 15 months.

The correct response is option B: The child is not standing by 15 months.

A child who is not standing by 15 months, not walking or using words by 20 months,
or not using phrases in speech by 30 months will be noticed, leading to efforts to
understand and remediate the delay (option B is correct; option D is incorrect).
This is not necessarily so for the more subtle manifestations of the development
of social communication, such as the use of facial expressions or gestures, the de-
gree of enthusiasm with which the child greets others (option A is incorrect), the
amount of time the child spends in meaningful eye contact, or whether the child
uses gestures to direct another person’s attention to things that interest the child
or that he or she wants (option C is incorrect). (Chapter 8, Autism Spectrum Dis-
orders/Definition, Clinical Description, and Diagnosis/Clinical Characteris-
tics, p. 138)

Autism Spectrum Disorders—Answer Guide | 149

8.3 Which two instruments are universally recognized as the most valid diagnostic
instruments available to diagnose autism?

A. Childhood Autism Rating Scale (CARS) and the Autism Diagnostic Observa-
tion Schedule—Generic (ADOS-G).
B. Modified Checklist for Autism in Toddlers (M-CHAT) and the Autism Diagnos-
tic Observation Schedule—Generic (ADOS-G).
C. Social Communication Questionnaire (SCQ) and the Autism Diagnostic Ob-
servation Schedule—Generic (ADOS-G).
D. Autism Diagnostic Interview—Revised (ADI-R) and the Autism Diagnostic Ob-
servation Schedule—Generic (ADOS-G).

The correct response is option D: Autism Diagnostic Interview—Revised (ADI-R)

and the Autism Diagnostic Observation Schedule—Generic (ADOS-G).

For children 3 years and older, the ADI-R (Lord et al. 1994) and the ADOS-G (Lord
et al. 2000) are universally recognized as the most comprehensive and valid diag-
nostic instruments available (option D is correct; options A, B, and C are incor-
rect). The SCQ (Rutter et al. 2003) (option C) is a 40-item parent survey derived
from the ADI-R. The Checklist for Autism in Toddlers (CHAT; Baron-Cohen et al.
1992) was developed for screening by pediatricians and nurses with children who
are ages 18–24 months. A modified version, the M-CHAT (Robins et al. 2001) (op-
tion B), improved diagnostic specificity. The CARS (Schopler et al. 2010) (option
A) combines elements of the structured interview with direct observations and
may be used for screening and diagnostic supplementation. (Chapter 8, Autism
Spectrum Disorders/Definition, Clinical Description, and Diagnosis/Diagnos-
tic Process/Evaluation Instruments, pp. 140–141)

8.4 What genetic test should be offered to individuals with autism?

A. Rett syndrome.
B. 22q11.2 deletion syndrome (velocardiofacial syndrome).
C. Angelman syndrome.
D. Fragile X syndrome.

The correct response is option D: Fragile X syndrome.

The cause of fragile X syndrome is a mutation in the gene FMR1. Approximately

3%–5% of persons diagnosed with autism spectrum disorder have the FMR1 mu-
tation (Farzin et al. 2006; Wassink et al. 2001). While small, this prevalence is suf-
ficient to warrant testing of all autistic persons for the mutation, if only because of
the implication for family genetic counseling (option D is correct). Rett syndrome
is one of the most common causes of severe intellectual disability in females. His-
torically, mutations in the gene MECP2 were associated solely with Rett syndrome.
Classic Rett syndrome is associated with a distinctive “regressive” presentation in
which there is a period of ostensibly normal development for the first 6–18 months

150 | Autism Spectrum Disorders—Answer Guide

 of life, followed by a rapid loss of intellectual functioning and fine and gross mo-
tor skills (option A is incorrect). 22q11.2 deletion syndrome (velocardiofacial syn-
drome) carries the highest genetic risk for developing schizophrenia (option B is
incorrect). Angelman syndrome has a prevalence of 1.4% in populations with se-
vere intellectual disability (King et al. 2005) (option C is incorrect). The characteris-
tic neurocognitive profile is severe speech impairment, inattention, gait ataxia
and/or tremulous movement of the limbs, inappropriate frequent laughter, happy
demeanor, and excitable personality (often with hand flapping). (Chapter 8, Autism
Spectrum Disorders/Definition, Clinical Description, and Diagnosis/Diagnostic
Process/Differential Diagnosis: Fragile X Syndrome, p. 141; Chapter 7, Intellectual
Disability/Congenital Syndromes and Neurobehavioral Phenotypes, pp. 117, 120)

8.5 Which of the following behavioral and psychosocial treatments has the greatest
evidence base for autism spectrum disorders?

A. Social Stories.
B. Developmental, Individual-Difference, Relationship-Based Approach (DIR).
C. Applied Behavioral Analysis (ABA).
D. Relationship Development Intervention (RDI).

The correct response is option C: Applied Behavioral Analysis (ABA).

ABA is one of the few therapies that has had some empirical validation (McEachin
et al. 1993) (option C is correct). Forms of ABA include discrete trial training, which
relies on the principles of operant conditioning, in which a stimulus (a question
or command) is presented to evoke a specific response. Reinforcers are provided
as a reward. A subsequent ABA approach, pivotal response training, was developed
with the goal of finding ways to increase the child’s motivation, responsiveness
to multiple cues, engagement in self-management, and self-initiation of social in-
teractions that were identified as “pivotal” factors in determining the success of
behavioral interventions. Social Stories is a technique developed by Carol Gray
(www.thegraycenter.org), in which a situation, skill, or concept is described in
terms of relevant social cues, perspectives, and common responses in a specifi-
cally defined style and format (option A is incorrect). DIR seems reasonable, but
no empirical studies with control groups have been published (option B is in-
correct). RDI is a parent-based, cognitive-developmental approach in which pri-
mary caregivers are trained. A small outcome study without control groups
(Gutstein et al. 2007) indicated that the method has promise (option D is incor-
rect). (Chapter 8, Autism Spectrum Disorders/Treatment/Behavioral Interven-
tions, pp. 146–148)

References
American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 4th Edi-
tion. Arlington, VA, American Psychiatric Association, 1994
American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 5th Edi-
tion. Arlington, VA, American Psychiatric Association, 2013

Autism Spectrum Disorders—Answer Guide | 151

Baron-Cohen S, Allen J, Gillberg C: Can autism be detected at 18 months? The needle, the hay-
stack, and the CHAT. Br J Psychiatry 161:839–843, 1992, 1483172
Farzin F, Perry H, Hessl D, et al: Autism spectrum disorders and attention-deficit/hyperactivity
disorder in boys with fragile X permutation. J Dev Behav Pediatr 27 (2 suppl):S137–S144, 2006
16685180
Gutstein SE, Burgess AF, Montfort K: Evaluation of the relationship development intervention
program. Autism 11(5):397–411, 2007 17942454
Huerta M, Lord C: Diagnostic evaluation of autism spectrum disorders. Pediatr Clin North Am
59(1):103–111, xi, 2012 22284796
King BH, Hodapp RM, Dykens EM: Mental retardation, in Kaplan and Sadock’s Comprehensive
Textbook of Psychiatry, Vol 2, 8th Edition. Edited by Kaplan HI, Sadock BJ. Baltimore, MD,
Lippincott Williams and Wilkins, 2005, pp 3076–3106
Lord C, Rutter M, Le Couteur A: Autism Diagnostic Interview-Revised: a revised version of a di-
agnostic interview for caregivers of individuals with possible pervasive developmental dis-
orders. J Autism Dev Disord 24(5):659–685, 1994 7814313
Lord C, Risi S, Lambrecht L, et al: The Autism Diagnostic Observation Schedule-Generic: a stan-
dard measure of social and communication deficits associated with the spectrum of autism.
J Autism Dev Disord 30(3):205–223, 2000 11055457
McEachin JJ, Smith T, Lovaas OI: Long-term outcome for children with autism who received early
intensive behavioral treatment. Am J Ment Retard 97(4):359–391, 1993 8427693
Robins DL, Fein D, Barton ML, et al: The Modified Checklist for Autism in Toddlers: an initial
study investigating the early detection of autism and pervasive developmental disorders.
J Autism Dev Disord 31(2):131–144, 2001 11450812
Rutter M, Bailey A, Lord C: Social Communication Questionnaire (SCQ). Los Angeles, CA, West-
ern Psychological Services, 2003
Schopler E, Van Bourgondien ME, Wellman GJ, et al: Childhood Autism Rating Scale, 2nd Edition.
Los Angeles, CA, Western Psychological Services, 2010
Wassink TH, Piven J, Patil SR: Chromosomal abnormalities in a clinic sample of individuals with
autistic disorder. Psychiatr Genet 11(2):57–63, 2001 11525418

152 | Autism Spectrum Disorders—Answer Guide

 C H A P T E R 9

Neurodevelopmental
Disorders
Specific Learning Disorder,
Communication Disorders, and
Motor Disorders
9.1 What is the most prevalent DSM-5 learning disorder (LD) in children receiving
special education services?

A. Mathematics disorder.
B. Dysgraphia.
C. Disorder of written expression.
D. Reading disorder.

The correct response is option D: Reading disorder.

In DSM-5 (American Psychiatric Association 2013), reading disorder is defined as

impairment of word reading accuracy, reading rate or fluency, or reading compre-
hension. Dyslexia has been suggested as an alternative term. Dyslexia is the most
prevalent LD in children receiving special education (option D is correct). In
DSM-5 specific learning disorder in mathematics is divided to include number
sense, memorization of arithmetic facts, accurate or fluent calculation, and accu-
rate math reasoning (option A is incorrect). Written expression is the last and most
complex skill to develop. The DSM-5 definition of disorder of written expression
includes impairment in spelling accuracy, grammar and punctuation, and clarity
or organization of written expression. Deficits in this area are not usually noticed
until fourth or fifth grade (option C is incorrect). Messy handwriting is often
called dysgraphia, defined as a neurological disorder where a person’s writing is
distorted or incorrect (option B is incorrect). (Chapter 9, Neurodevelopmental
Disorders: Specific Learning Disorder, Communication Disorders, and Motor
Disorders/Learning Disorders, pp. 159–165)

153
9.2 With regard to defining learning disorders (LDs), which of the following statements
is true?

A. The federal government’s definition used by classroom teachers classifies LDs

in the same way that DSM-5 does.
B. The threshold for positive identification of LDs and the definition and catego-
ries of special education vary from state to state.
C. In DSM-5 the LD definitions were not changed from DSM-IV.
D. In defining LDs, the various categorical systems often agree.

The correct response is option B: The threshold for positive identification of LDs
and the definition and categories of special education vary from state to state.

In defining LDs or communication disorders, the various categorical systems of-

ten do not agree or even define the same disorder (option D is incorrect). In DSM-
5 these disorders are included under the category of neurodevelopmental disorders.
The federal government’s definition used by classroom teachers classifies these
disorders somewhat differently (option A is incorrect). Even with special educa-
tion mandates from the federal government, the threshold for positive identifica-
tion of LDs and the definition and categories of special education vary from state
to state (option B is correct), causing widely discrepant prevalence rates. For
DSM-5 the LD definitions were changed significantly and were placed under neu-
rodevelopmental disorders (option C is incorrect). (Chapter 9, Neurodevelop-
mental Disorders: Specific Learning Disorder, Communication Disorders, and
Motor Disorders, pp. 157, 159)

9.3 Which of the following is the unexpected disturbance in the normal patterns and
flow of speech?

A. Expressive language disorder.

B. Receptive language disorder.
C. Childhood-onset fluency disorder.
D. Speech sound disorder.

The correct response is option C: Childhood-onset fluency disorder.

Childhood-onset fluency disorder (stuttering) is the unexpected disturbance in

the normal patterns and flow of speech (option C is correct). DSM-5 speech sound
disorder includes difficulties with articulation, such as the inability to use expected
speech sounds appropriate for the child’s age and dialect, that interfere with com-
munication (option D is incorrect). Receptive language is the comprehension of
single words, language concepts, directions, grammar, concrete/abstract lan-
guage, auditory memory, inferential reasoning, phonological processing (reading
readiness), and combined linguistic skills (option B is incorrect). Expressive language
uses vocabulary, word retrieval by context, semantic association skills, grammar,
narrative skills, and pragmatic/social language skills (Rhea 2007) (option A is

154 | Neurodevelopmental Disorders—Answer Guide

 incorrect). (Chapter 9, Neurodevelopmental Disorders: Specific Learning Dis-
order, Communication Disorders, and Motor Disorders/Communication Disor-
ders, p. 166)

9.4 In addition to social (pragmatic) communication disorder, which of the following

should be included on the differential diagnosis of a child presenting with prag-
matic language deficits?

A. Attention-deficit/hyperactivity disorder (ADHD).

B. Speech sound disorder.
C. Childhood-onset fluency disorder.
D. Developmental coordination disorder.

The correct response is option A: Attention-deficit/hyperactivity disorder

(ADHD).

Pragmatics is the application of language in social or learning situations for prob-

lem solving or in expressing affect. Pragmatic disorders occur when there are dif-
ficulties in using language in a social, situational, or communication context.
Children with ADHD have been shown to have a variety of pragmatic deficits
(Haynes et al. 2006) (option A is correct). DSM-5 speech sound disorder includes
difficulties with articulation, such as the inability to use expected speech sounds
appropriate for the child’s age and dialect, that interfere with communication (op-
tion B is incorrect). Childhood-onset fluency disorder (stuttering) is the unexpected
disturbance in the normal patterns and flow of speech (option C is incorrect). Mo-
tor disorders and poor coordination are also known as clumsiness or dyspraxia;
in DSM-5, the term developmental coordination disorder is used and includes both
fine and gross motor problems that interfere with academic achievement (option
D is incorrect). (Chapter 9, Neurodevelopmental Disorders: Specific Learning
Disorder, Communication Disorders, and Motor Disorders, pp. 166–168)

9.5 Which of the following cognitive skills is the last and most complex skill to develop?

A. Number sense.
B. Phonological awareness.
C. Word recognition.
D. Written expression.

The correct response is option D: Written expression.

Written expression is the last and most complex skill to develop. The DSM-5 defi-
nition of disorder of written expression includes impairment in spelling accuracy,
grammar and punctuation, and clarity or organization of written expression.
Deficits in this area are not usually noticed until fourth or fifth grade, when the
curriculum requires higher-level language and written organization skills (option
D is correct). Research suggests that number sense, or the ability to represent and
discriminate numbers and to perform arithmetic operations with a limited degree

Neurodevelopmental Disorders—Answer Guide | 155

 of accuracy, develops early (Feigenson 2005), between ages 2 and 4 years (option
A is incorrect). Phonological awareness is a basic building block of reading. It is the
metacognitive ability to understand the words we hear and read that have basic
structure related to sound (option B is incorrect). Word recognition is a basic build-
ing block of reading. Word-level reading disability or dyslexia is characterized by
difficulty in single-word decoding. Without the ability to read a word, fluency and
understanding are limited (option C is incorrect). (Chapter 9, Neurodevelopmen-
tal Disorders: Specific Learning Disorder, Communication Disorders, and Mo-
tor Disorders/Learning Disorders, pp. 162–165)

References
American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 5th Edi-
tion. Arlington, VA, American Psychiatric Association, 2013
Feigenson L: A double-dissociation in infants’ representations of object arrays. Cognition 95(3):B37–
B48, 2005 15788156
Haynes WO, Pindzola R, Moran M: Communication Disorders in the Classroom: An Introduction
for Professionals in School Settings. Boston, MA, Jones and Bartlett, 2006
Rhea P: Language Disorders From Infancy Through Adolescence. St. Louis, MO, CV Mosby, 2007

156 | Neurodevelopmental Disorders—Answer Guide

 C H A P T E R 1 0

Attention-Deficit/
Hyperactivity Disorder

10.1 What change has been made in the diagnostic criteria for attention-deficit/hyper-
activity disorder (ADHD) in DSM-5?

A. Symptoms can also be accounted for by some other psychiatric condition.

B. Several symptoms are required to be present before age 12 years.
C. Individual symptom descriptions have been narrowed.
D. ADHD cannot be diagnosed concurrently with autism spectrum disorder.

The correct response is option B: Several symptoms are required to be present

before age 12 years.

ADHD is a neurodevelopmental disorder in which a child’s ability to attend to

and control impulses (including inhibiting motor activity when appropriate) 1) is
significantly less than that of a typically developing child, 2) causes impairment
in the child’s academic or social functioning, and 3) is not accounted for by some
other medical or psychiatric condition (option A is incorrect). In DSM-5 (Ameri-
can Psychiatric Association 2013), the age at onset has been significantly changed
from the criteria in DSM-IV (American Psychiatric Association 1994); some symp-
toms are now required to be present before age 12 years (formerly age 7 years)
(option B is correct). The individual symptom descriptions have been broadened
to include behaviors typical of an adolescent or adult rather than only young chil-
dren (option C is incorrect). Another change is that the diagnosis of ADHD now
may be made in the presence of autism spectrum disorder (option D is incorrect).
(Chapter 10, Attention-Deficit/Hyperactivity Disorder/Definition, Clinical De-
scription, and Diagnosis, p. 175)

157
10.2 Which of the following is a true statement regarding the genetic contribution to
attention-deficit/hyperactivity disorder (ADHD)?

A. A large percentage of the variance in ADHD traits is attributable to genetics.

B. Heritability rates in ADHD minimize the effect of the environment.
C. A gene variant with genomewide significance has been discovered.
D. Copy number variants are found less often in patients with ADHD.

The correct response is option A: A large percentage of the variance in ADHD

traits is attributable to genetics.

In twin studies comparing concordance rates for ADHD in monozygotic and di-
zygotic twins to determine the relative influence of genes and the environment on
the variance in symptoms of ADHD, about 71%–90% of the variance in ADHD
traits was found to be attributable to genetics (Thapar et al. 2013) (option A is cor-
rect). Heritability estimates included the effects of gene–environment interaction;
thus, the high heritability rates in ADHD do not minimize the effect of environ-
ment (option B is incorrect). Genomewide association studies involving tens of
thousands of subjects have not revealed any gene variant that passes the very high
statistical threshold for genomewide significance (Neale et al. 2010) (option C is
incorrect). There is evidence that small deletions or duplications of parts of chro-
mosomes (copy number variants) are found more often in patients with ADHD,
particularly those with comorbid developmental disabilities (Williams et al. 2010)
(option D is incorrect). (Chapter 10, Attention-Deficit/Hyperactivity Disorder/
Etiology and Risk Factors/Genetics, p. 177)

10.3 Which of the following is an established risk factor for the development of
ADHD?

A. Maternal smoking during pregnancy.

B. Post-term pregnancy.
C. Low Apgar scores.
D. Small size for gestational age.

The correct response is option A: Maternal smoking during pregnancy.

Maternal smoking during pregnancy and prenatal/perinatal adversity have been

established as risk factors for ADHD (Mick et al. 2002a, 2002b). Children with
ADHD exposed to smoking during pregnancy are at risk for more severe behav-
ioral problems, lower IQ, and poorer neuropsychological test performance than
nonexposed children with ADHD (Thakur et al. 2013), even when income level,
ethnicity, and mother’s age and alcohol use are controlled for (option A is correct).
In contrast, low birth weight, post-term pregnancy, small size for gestational age,
fetal distress, and low Apgar scores were not found to be related to ADHD (options
B, C, and D are incorrect). (Chapter 10, Attention-Deficit/Hyperactivity Disor-
der/Etiology and Risk Factors/Environmental Risk Factors, pp. 177–178)

158 | Attention-Deficit/Hyperactivity Disorder—Answer Guide

10.4 Which brain system identified in functional magnetic resonance imaging (fMRI)
studies is specialized for detecting relevant stimuli and novelty, and is also a key
region for response inhibition?

A. Ventral striatum.
B. Temporoparietal junction and inferior frontal cortex.
C. Anterior cingulate cortex.
D. Dorsolateral prefrontal cortex and intraparietal sulcus.

The correct response is option B: Temporoparietal junction and inferior frontal

cortex.

Functional magnetic resonance imaging (fMRI) studies in healthy control subjects

indicate that the temporoparietal junction and inferior frontal cortex are special-
ized for detecting relevant stimuli; this system also responds to novelty. Interest-
ingly, it is right-lateralized, with the right inferior frontal cortex a key region for
response inhibition (option B is correct). The ventral striatum is critical to modu-
lating response to rewarding stimuli (option A is incorrect). The anterior cingu-
late cortex is a key region for monitoring ongoing behavior and responding to
error; increased activity of the anterior cingulate cortex when an error is made
leads to improved accuracy on future trials (Carter et al. 1999) (option C is incor-
rect). The frontal eye fields, dorsolateral prefrontal cortex, and intraparietal sulcus
are part of the “top-down” system that prepares and applies goal-directed selec-
tion for stimuli and responses (Corbetta and Shulman 2002) (option D is incor-
rect). (Chapter 10, Attention-Deficit/Hyperactivity Disorder/Pathophysiology/
Neurocircuitry, pp. 178–180)

10.5 What is an essential element in diagnosing attention-deficit/hyperactivity disorder

(ADHD)?

A. Psychological testing.
B. Sleep study.
C. Interview with parent.
D. Neurological examination.

The correct response is option C: Interview with parent.

The clinician should perform a detailed interview with the parent about each of the
18 ADHD symptoms listed in DSM-5. If a symptom is present, the clinician should
inquire about its duration, severity, and frequency. The diagnosis of ADHD requires
a chronic course (symptoms do not remit for weeks or months at a time) and onset
of symptoms during childhood. After all the symptoms are assessed, the clinician
should determine in which settings (school, work, home) impairment occurs (op-
tion C is correct). IQ testing and achievement testing to rule out learning disorders
are not mandatory prior to making a diagnosis of ADHD (option A is incorrect).
A sleep study is not indicated if symptoms of sleep-disordered breathing are not
present (option B is incorrect). A neurological examination is not contributory to

Attention-Deficit/Hyperactivity Disorder—Answer Guide | 159

 the diagnosis of ADHD. Children with ADHD may have more nonfocal “soft
signs” on a neurological examination than children without ADHD, but such signs
are not diagnostic and do not have relevance for selection of treatment (Pine et al.
1993) (option D is incorrect). (Chapter 10, Attention-Deficit/Hyperactivity Dis-
order/Clinical Evaluation, pp. 182–184)

10.6 What is the principal treatment for the core symptoms of attention-deficit/hyper-
activity disorder (ADHD)?

A. Pharmacotherapy.
B. Behavioral treatment.
C. Neurofeedback.
D. Artificial food color elimination diet.

The correct response is option A: Pharmacotherapy.

Pharmacological treatment of ADHD is the best studied intervention in child and

adolescent psychiatry. The principal treatment for ADHD is pharmacological, in-
volving stimulants, atomoxetine, and α agonists (option A is correct). A meta-
analysis of randomized controlled trials of psychological treatments showed a
modest and statistically significant effect of behavioral therapy on parent ratings
of ADHD behavior but no effect on the blinded observer ratings (Sonuga-Barke
et al. 2013). Daley et al. (2014) performed an additional meta-analysis of random-
ized controlled trials in youth with ADHD and found that behavioral treatment
showed stronger effects for a range of parenting behaviors and conduct problems
than for core ADHD symptoms (option B is incorrect). Neurofeedback is not effi-
cacious in the treatment of ADHD (option C is incorrect). Stevenson et al. (2014)
reviewed meta-analyses of randomized controlled trials of three dietary treat-
ments: restricted elimination diets, artificial food color elimination, and supple-
mentation with free fatty acids. There was a modest effect size (0.17–0.42) for all
three types of dietary intervention. The opinion of the authors was that much larger
trials with stronger methodology were required (option D is incorrect). (Chapter 10,
Attention-Deficit/Hyperactivity Disorder/Treatment, pp. 184–189)

References
American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 4th Edi-
tion. Arlington, VA, American Psychiatric Association, 1994
American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 5th Edi-
tion. Arlington, VA, American Psychiatric Association, 2013
Carter CS, Botvinick MM, Cohen JD: The contribution of the anterior cingulate cortex to executive
processes in cognition. Rev Neurosci 10(1):49–57, 1999 10356991
Corbetta M, Shulman GL: Control of goal-directed and stimulus-driven attention in the brain. Nat
Rev Neurosci 3(3):201–215, 2002 11994752
Daley D, van der Oord S, Ferrin M, et al: Behavioral interventions in attention-deficit/hyperactiv-
ity disorder: a meta-analysis of randomized controlled trials across multiple outcome do-
mains. J Am Acad Child Adolesc Psychiatry 53(8):835–847, 2014 25062591

160 | Attention-Deficit/Hyperactivity Disorder—Answer Guide

Mick E, Biederman J, Faraone SV, et al: Case-control study of attention-deficit hyperactivity disor-
der and maternal smoking, alcohol use, and drug use during pregnancy. J Am Acad Child
Adolesc Psychiatry 41(4):378–385, 2002a 11931593
Mick E, Biederman J, Prince J, et al: Impact of low birth weight on attention-deficit hyperactivity
disorder. J Dev Behav Pediatr 23(1):16–22, 2002b 11889347
Neale BM, Medland SE, Ripke S, et al: Meta-analysis of genome-wide association studies of atten-
tion-deficit/hyperactivity disorder. J Am Acad Child Adolesc Psychiatry 49(9):884–897, 2010
20732625
Pine D, Shaffer D, Schonfeld IS: Persistent emotional disorder in children with neurological soft
signs. J Am Acad Child Adolesc Psychiatry 32(6):1229–1236, 1993 8282669
Sonuga-Barke EJ, Brandeis D, Cortese S, et al: Nonpharmacological interventions for ADHD: sys-
tematic review and meta-analyses of randomized controlled trials of dietary and psycholog-
ical treatments. Am J Psychiatry 170(3):275–289, 2013 23360949
Stevenson J, Buitelaar J, Cortese S, et al: Research review: the role of diet in the treatment of atten-
tion-deficit/hyperactivity disorder—an appraisal of the evidence on efficacy and recommen-
dations on the design of future studies. J Child Psychol Psychiatry 55(5):416–427, 2014
24552603
Thakur GA, Sengupta SM, Grizenko N, et al: Maternal smoking during pregnancy and ADHD: a
comprehensive clinical and neurocognitive characterization. Nicotine Tob Res 15(1):149–157,
2013 22529219
Thapar A, Cooper M, Eyre O, et al: What have we learnt about the causes of ADHD? J Child Psy-
chol Psychiatry 54(1):3–16, 2013 22963644
Williams NM, Zaharieva I, Martin A, et al: Rare chromosomal deletions and duplications in atten-
tion-deficit hyperactivity disorder: a genome-wide analysis. Lancet 376(9750):1401–1408,
2010 20888040

Attention-Deficit/Hyperactivity Disorder—Answer Guide | 161

 C H A P T E R 1 1

Oppositional Defiant
Disorder and
Conduct Disorder
11.1 Which of the following psychiatric disorders is the most common comorbid con-
dition found with oppositional defiant disorder (ODD)?

A. Mood disorder.
B. Attention-deficit/hyperactivity disorder (ADHD).
C. Separation anxiety disorder.
D. Obsessive-compulsive disorder.

The correct response is option B: Attention-deficit/hyperactivity disorder

(ADHD).

ADHD is the most common comorbid condition found with ODD, and, con-
versely, many children with ADHD also have ODD (option B is correct). Children
with ADHD may be described as disobedient when actually their poor compli-
ance is due to inattention and forgetfulness rather than willful defiance. Another
important consideration is the possible presence of an anxiety disorder. Separa-
tion anxiety disorder and obsessive-compulsive disorder may initially present
with complaints of severe tantrums. Children with ODD appear to be at higher
risk for developing an anxiety disorder. Similar consideration should be given for
the mood disorders, as antagonistic and disobedient behaviors are often associ-
ated features for children with mood disorders and studies indicate that children
with ODD are at similar increased risk for a comorbid mood disorder. (Chapter
11, Oppositional Defiant Disorder and Conduct Disorder/Oppositional Defi-
ant Disorder/Comorbidity, p. 197)

11.2 Which of the following environmental factors is correlated with increased risk for
oppositional defiant disorder (ODD)?

A. Fair and consistent limit setting.

B. Higher socioeconomic status.

163
 C. Domestic violence.
D. High family cohesion.

The correct response is option C: Domestic violence.

Various environmental factors are correlated with increased risk for ODD. Lower
socioeconomic status is associated with risk (option B is incorrect), but this is
probably mediated through family stresses and resulting dysfunction. Many
other family attributes are correlated with higher rates of oppositional behaviors,
including poor parenting practices; parental discord; domestic violence (option C
is correct); low family cohesion (option D is incorrect); child abuse; and parental
mental disorder, especially substance abuse and antisocial personality disorder.
Mothers of children at increased risk for oppositional and disruptive behaviors
report feeling less competent as parents, have fewer solutions for child behavior
problems, and are less assertive in management of child misbehavior (Cunning-
ham and Boyle 2002). Studies also support that harsh or inconsistent limit setting
is predictive of later oppositional and antisocial behaviors (option A is incorrect).
(Chapter 11, Oppositional Defiant Disorder and Conduct Disorder/Opposi-
tional Defiant Disorder/Etiology, Mechanisms, and Risk Factors/Sociological
Factors, p. 199)

11.3 Which of the following is an evidence-based treatment for oppositional defiant

disorder (ODD)?

A. Stimulants.
B. Atypical antipsychotics.
C. Psychodynamic psychotherapy.
D. Parent management training.

The correct response is option D: Parent management training.

No evidence exists to support an indication for specific medication use in treat-

ment of ODD per se (options A and B are incorrect). There are reports of reduction
in oppositional behaviors with indicated pharmacological treatment of concur-
rent disorders such as attention-deficit/hyperactivity disorder (ADHD). Medica-
tions for ADHD, including stimulants, guanfacine, and clonidine, have been noted
to reduce comorbid oppositional behaviors along with the primary symptoms of
inattention, hyperactivity, and impulsivity. There are clinical reports that atomox-
etine (Bangs et al. 2008) can reduce ODD behaviors in children with comorbid
ADHD. Other symptoms of ODD may be reduced with medication treatment of
more severe physical aggression, including the antipsychotic and mood stabiliz-
ing agents, but these medications have not been studied in youth with only ODD
(option B is incorrect). Reviews and meta-analytic studies have identified several
promising, evidence-based treatment approaches. Of these, parent management
training and child problem-solving skills training have demonstrated the greatest
efficacy with ODD (option D is correct). Parent management training indirectly

164 | Oppositional Defiant Disorder and Conduct Disorder—Answer Guide

 affects child behavior by improving parent skills in dealing with negative acts and
promoting desired behaviors. Child problem-solving skills training derives from
cognitive-behavioral therapy techniques in correcting dysfunctional social inter-
actions and focuses on delaying impulsive responses, increasing reflection on alter-
native solutions, anticipating consequences, and practicing self-assessment of
behaviors. (Chapter 11, Oppositional Defiant Disorder and Conduct Disorder/
Oppositional Defiant Disorder/Treatment, pp. 201–202)

11.4 Which of the following is true of childhood-onset conduct disorder (CD) when
compared with adolescent-onset CD?

A. Patients with childhood-onset CD are more likely to have higher IQ.

B. Those with childhood-onset CD are more likely to have comorbid attention-
deficit/hyperactivity disorder (ADHD).
C. Those with childhood-onset CD are less likely to have co-occurring neuropsy-
chiatric disorders.
D. Those with childhood-onset CD tend to have less severe disruptive and anti-
social behaviors into adolescence and adulthood.

The correct response is option B: Those with childhood-onset CD are more likely
to have comorbid ADHD.

Patients with childhood-onset CD appear to have a different risk profile than

those with adolescent onset, including higher rates of ADHD (option B is correct),
low IQ (option A is incorrect), and other neuropsychiatric disorders (option C is
incorrect). Research indicates that individuals with childhood onset are at greater
risk than those with adolescent onset for continued and more severe disruptive
and antisocial behaviors (option D is incorrect). (Chapter 11, Oppositional Defi-
ant Disorder and Conduct Disorder/Conduct Disorder/Definition, Clinical De-
scription, and Diagnosis/Epidemiology, p. 204; Comorbidity, p. 206)

11.5 Which of the following statements is true regarding increased risk for onset or fur-
ther development of conduct disorder (CD)?

A. Intrauterine exposure to toxic substances increases the risk of CD.

B. Researchers have concluded that CD does not have a genetic basis for inheri-
tance and its development is purely environmental.
C. Low intelligence is associated with conduct problems, but verbal abilities are
not.
D. Children who have been sexually abused are more likely to develop CD, but the
same is not true of physical abuse and neglect.

The correct response is option A: Intrauterine exposure to toxic substances in-

creases the risk of CD.

Oppositional Defiant Disorder and Conduct Disorder—Answer Guide | 165

 Development of antisocial behaviors is associated with early toxic exposures, such as
lead (Needleman et al. 1996) and opiates and methadone (prenatal) (deCubas and
Field 1993) (option A is correct). Maternal smoking during pregnancy also in-
creases risk for CD whether or not there is comorbid attention-deficit/hyperactivity
disorder (ADHD) (Wakschlag et al. 2006). Children exposed to prenatal maternal
smoking were also more likely to have an earlier onset of delinquent behavior.
The occurrence of cases within families and differences in risk by gender support
the view of possible genetic influences on CD. Antisocial behavior is likely a poly-
genetic phenomenon, with different genes being expressed at different stages of
development, although certain genes may be associated with specific behaviors
(Burt and Mikolajewski 2008). Studies report a moderate degree of heritability for
aggression, delinquency, and antisocial behavior from childhood to adulthood (op-
tion B is incorrect). A meta-analytic review of studies conducted by Hogan (1999)
found that comorbid ADHD accounted for any relationship between CD and low
intelligence, but a more recent study (Simonoff et al. 2004) indicated that low in-
telligence was significantly correlated with conduct problems. Impaired verbal
ability is significantly associated with antisocial behaviors even after controlling
for other possible confounds, including race, socioeconomic status, and academic
achievement (Moffitt et al. 1993). A key factor in the association between deficits
in verbal abilities and antisocial behaviors may be the additional presence of at-
tention problems (Lahey et al. 1995) (option C is incorrect). One study reported that
sexually abused children were 12 times more likely to develop CD, even when con-
trolling for other factors, although further research in this area is needed (Trickett
and Putnam 1998). Physical abuse and neglect are particularly associated with
later aggressive and violent behavior (option D is incorrect). (Chapter 11, Oppo-
sitional Defiant Disorder and Conduct Disorder/Conduct Disorder/Etiology,
Mechanisms, and Risk Factors/Biological Factors, pp. 206–208)

References
Bangs ME, Hazell P, Danckaerts M, et al: Atomoxetine for the treatment of attention-deficit/hy-
peractivity disorder and oppositional defiant disorder. Pediatrics 121(2):e314–e320, 2008
18245404
Burt SA, Mikolajewski AJ: Preliminary evidence that specific candidate genes are associated with
adolescent-onset antisocial behavior. Agress Behav 34(4):437–445, 2008 18366104
Cunningham CE, Boyle MH: Preschoolers at risk for attention-deficit hyperactivity disorder and
oppositional defiant disorder: family, parenting, and behavioral correlates. J Abnorm Child
Psychol 30(6):555–569, 2002 12481971
deCubas MM, Field T: Children of methadone-dependent women: developmental outcomes. Am
J Orthopsychiatry 63(2):266–276, 1993 7683453
Hogan AE: Cognitive functioning in children with oppositional defiant disorder and conduct dis-
order, in Handbook of Disruptive Behavior Disorders. Edited by Quay HC, Hogan AE. New
York, Kluwer Academic/Plenum, 1999, pp 317–335
Lahey BB, Loeber R, Hart EL, et al: Four-year longitudinal study of conduct disorder in boys: pat-
terns and predictors of persistence. J Abnorm Psychol 104(1):83–93, 1995 7897057
Moffitt TE, Caspi A, Harkness AR, et al: The natural history of change in intellectual performance:
who changes? How much? Is it meaningful? J Child Psychol Psychiatry 34(4):455–506, 1993
8509490

166 | Oppositional Defiant Disorder and Conduct Disorder—Answer Guide

Needleman HL, Riess JA, Tobin MJ, et al: Bone lead levels and delinquent behavior. JAMA 275(5):
363–369, 1996 8569015
Simonoff E, Elander J, Holmshaw J, et al: Predictors of antisocial personality. Continuities from
childhood to adult life. Br J Psychiatry 184:118–127, 2004 14754823
Trickett PK, Putnam FW: Developmental consequences of child sexual abuse, in Violence Against
Children in the Family and the Community. Edited by Trickett PK, Schellenbach CJ. Washing-
ton, DC, American Psychological Association, 1998, pp 39–56
Wakschlag LS, Pickett KE, Kasza KE, et al: Is prenatal smoking associated with a developmental
pattern of conduct problems in young boys? J Am Acad Child Adolesc Psychiatry 45(5):461–
467, 2006 16601651

Oppositional Defiant Disorder and Conduct Disorder—Answer Guide | 167

 C H A P T E R 1 2

Substance Use Disorders

and Addictions
12.1 Which of the following statements best explains increased vulnerability to emer-
gence of a substance use disorder (SUD) during adolescence?

A. Adolescence is characterized by an imbalance between early emerging subcor-

tical systems that may express reactivity to motivational stimuli and later-
developing cognitive control regions, which include executive functions.
B. The risk of progression to an SUD is only associated with the use of illegal sub-
stances.
C. Compromise of reward mechanisms does not affect the risk for SUDs.
D. During adolescence, cognitive control processes are less vulnerable to incentive-
based (reward) modulation.

The correct response is option A: Adolescence is characterized by an imbalance

between early emerging subcortical systems that may express reactivity to mo-
tivational stimuli and later-developing cognitive control regions, which include
executive functions.

Understanding the risk for the development of SUDs can be noted in the emerg-
ing view of adolescence as characterized by an imbalance between early emerg-
ing subcortical “bottom-up” systems (i.e., more primitive and earlier developing
parts of the brain) that may express reactivity to motivational stimuli and later de-
veloping “top-down” cognitive control regions, which include executive functions
(Casey and Jones 2010) (option A is correct). Studies show curvilinear develop-
ment of the subcortical brain regions, with a peak from 13 to 17 years. In contrast,
prefrontal regions, the top-down cortical regions, show a linear pattern of devel-
opment into young adulthood that parallels that seen in behavioral studies of im-
pulsivity. The imbalance between these developing systems during adolescence
may lead to cognitive control processes being more vulnerable to incentive-based
(reward) modulation and increased susceptibility to the motivational properties
of alcohol and other drugs (option D is incorrect). Psychopathology that further
compromises reward mechanisms and increases impulsivity (e.g., attention-deficit
hyperactivity disorder [ADHD]) further increases the risk for SUDs (option C is in-

169
 correct). The risk for and rate of progression to SUD is the same whether consumption
begins with a legal or an illegal drug (option B is incorrect). Although answer C
is a true statement, it addresses risk factors for development of an SUD across the
life span, rather than the effect of compromised reward mechanisms on brain struc-
ture development. (Chapter 12, Substance Use Disorders and Addictions/Etiology,
Mechanisms, and Risk Factors, pp. 225–226)

12.2 What constitutes the major change between DSM-IV and DSM-5 criteria for clas-
sifying substance use?

A. The new DSM-5 diagnosis of substance use disorder (SUD) requires a threshold
of five physical signs and symptoms from the former DSM-IV criterion lists for
both abuse and dependence.
B. Severity specifiers in DSM-5 but not in DSM-IV are determined by the number
of substances abused.
C. DSM-IV diagnoses of abuse and dependence are replaced in DSM-5 by a sin-
gle diagnosis of SUD, specified by the type of substance involved.
D. The terms addiction and chemical dependency are operationally defined in DSM-5
but not in DSM-IV.

The correct response is option C: DSM-IV diagnoses of abuse and dependence

are replaced in DSM-5 by a single diagnosis of SUD, specified by the type of
substance involved.

DSM-5 (American Psychiatric Association 2013) presents a significant departure

from the DSM-IV (American Psychiatric Association 1994) nomenclature for SUDs.
Replacing the two DSM-IV SUD diagnoses of abuse and dependence is a single
diagnosis—substance use disorder, specified by the type of substance involved
(option C is correct). This change is well suited to adolescents, whose alcohol and
drug symptom profiles appear to vary along a severity dimension, rather than fit-
ting into DSM-IV’s abuse and dependence categories (Chung and Martin 2005).
A DSM-5 SUD diagnosis comprises 11 behavioral and physical signs and symp-
toms (listed in Criterion A) taken from the criterion list for DSM-IV for both abuse
and dependence, with a threshold of two symptoms necessary to receive an SUD di-
agnosis (option A is incorrect). Severity specifiers—mild, moderate, and severe—
are determined by the number of symptoms present (option B is incorrect). Many
clinicians do not use the DSM criteria, preferring to use single terms such as addic-
tion or chemical dependency to label substance use pathology. Usually, these terms
are not operationally defined (no specific criteria are used) (option D is incorrect).
(Chapter 12, Substance Use Disorders and Addictions/Definitions, Clinical De-
scription, and Diagnosis/Substance Use, pp. 219–220)

12.3 Which of the following pharmacological agents for the treatment of attention-
deficit/hyperactivity disorder has the highest potential for abuse and diversion?

A. Bupropion.
B. Atomoxetine.

170 | Substance Use Disorders and Addictions—Answer Guide

 C. Osmotic-release oral system methylphenidate.
D. α-Agonists.

The correct response is option C: Osmotic-release oral system methylphenidate.

Some commonly used pharmacological agents such as psychostimulants have in-

herent abuse potential (option C is correct). The long-acting stimulant prepa-
rations may offer less potential for abuse or diversion because of their form of
administration, reduced level of reinforcement due to more gradual and longer
time to maximum plasma concentration, and ability to more easily monitor and
supervise once-a-day dosing. Osmotic-release oral system methylphenidate and
lisdexamfetamine have minimal, if any, effects if snorted or injected. The clinician
should consider alternative agents to psychostimulants, such as atomoxetine (op-
tion B is incorrect), α-agonists (option D is incorrect), and bupropion (option A is
incorrect), which do not have abuse potential. (Chapter 12, Substance Use Disor-
ders and Addictions/Treatment/Pharmacological Treatments/Comorbid Psychi-
atric Disorders, p. 235)

12.4 Which of the following therapies has the most empirical support for use in the
treatment of adolescent substance use disorders (SUDs)?

A. Motivational interviewing.
B. Cognitive-behavioral therapy.
C. Contingency management.
D. Family therapies.

The correct response is option D: Family therapies.

Family therapy approaches for treatment of adolescent SUDs have the most empirical
support (Tanner-Smith et al. 2013; Waldron and Turner 2008; Williams et al. 2000)
(option D is correct; options A, B, and C are incorrect). Cognitive-behavioral ther-
apy is also effective and likely the most cost-effective (French et al. 2008). Motiva-
tional interviewing has resulted in significant improvements in substance use
outcomes. Contingency management approaches using contingency contracting
and vouchers also appear to be promising (Stanger and Budney 2010). (Chapter 12,
Substance Use Disorders and Addictions/Treatment/Psychotherapeutic Treat-
ments, p. 236)

12.5 Which of the following circumstances would force a clinician to break confidenti-
ality on behalf of an adolescent patient?

A. A positive urine toxicology test.

B. Illegal behavior, such as selling drugs.
C. Disclosure of recent sexual abuse.
D. Parental request for details on specific behaviors.

The correct response is option C: Disclosure of recent sexual abuse.

Substance Use Disorders and Addictions—Answer Guide | 171

 Both the Health Insurance Portability and Accountability Act and state law (in
most states) protect confidential information that an adolescent may provide
during assessment and/or treatment. Adolescents are more likely to provide
truthful information if they believe that their information will not be shared. Typ-
ically, a clinician should inform the adolescent that a threat of danger to self or
others or information about physical or sexual abuse will force the clinician to re-
veal otherwise confidential information (option C is correct). Confidentiality stat-
utes include information about illegal behavior such as selling drugs (option B is
incorrect). In order for the assessment team to speak with the adolescent’s family,
school, or legal staff members, the adolescent must sign a consent form. In some
states, parents must also sign a consent form. Toxicological tests to detect the pres-
ence of specific substances should be part of the formal evaluation and the ongo-
ing assessment of substance use in substance use disorder treatment settings.
Prior to testing, the clinician should establish rules regarding the confidentiality
of the results (option A is incorrect). The clinician should discuss what information
the adolescent will allow the clinician to reveal, such as a general recommenda-
tion for treatment or impressions rather than a detailed report of specific behaviors
(option D is incorrect). (Chapter 12, Substance Use Disorders and Addictions/
Levels of Assessment, pp. 230–231)

References
American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 4th Edi-
tion. Arlington, VA, American Psychiatric Association, 1994
American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 5th Edi-
tion. Arlington, VA, American Psychiatric Association, 2013
Casey BJ, Jones RM: Neurobiology of the adolescent brain and behavior: implications for sub-
stance use disorders. J Am Acad Child Adolesc Psychiatry 49(12):1189–1201, quiz 1285, 2010
21093769
Chung T, Martin CS: Classification and short-term course of DSM-IV cannabis, hallucinogen, co-
caine, and opioid disorders in treated adolescents. J Consult Clin Psychol 73(6):995–1004, 2005
16392973
French MT, Zavala SK, McCollister KE, et al: Cost-effectiveness analysis of four interventions for
adolescents with a substance use disorder. J Subst Abuse Treat 34(3):272–281, 2008 17600651
Stanger C, Budney AJ: Contingency management approaches for adolescent substance use disor-
ders. Child Adolesc Psychiatr Clin N Am 19(3):547–562, 2010 19951806
Tanner-Smith EE, Wilson SJ, Lipsey MW: The comparative effectiveness of outpatient treatment
for adolescent substance abuse: a meta-analysis. J Subst Abuse Treat 44(2):145–158, 2013
22763198
Waldron HB, Turner CW: Evidence-based psychosocial treatments for adolescent substance abuse.
J Clin Child Adolesc Psychol 37(1):238–261, 2008 18444060
Williams RJ, Chang SY, Addiction Centre Adolescent Research Group: A comprehensive and com-
parative review of adolescent substance abuse treatment outcome. Clinical Psychology: Sci-
ence and Practice 7:138–166, 2000

172 | Substance Use Disorders and Addictions—Answer Guide

 C H A P T E R 1 3

Depressive and Disruptive

Mood Dysregulation
Disorders
13.1 A 15-year-old female with a history of major depressive disorder (MDD), recurrent,
severe, continues to be symptomatic in spite of 16 weeks of treatment with fluoxe-
tine 40 mg/day. Which of the following would be the next appropriate step?

A. Switch to another selective serotonin reuptake inhibitor (SSRI).

B. Switch to venlafaxine.
C. Switch to venlafaxine and add cognitive-behavioral therapy (CBT).
D. Continue to increase the fluoxetine dosage.

The correct response is option C: Switch to venlafaxine and add cognitive-

behavioral therapy (CBT).

In the Treatment of Resistant Depression in Adolescents (TORDIA; Brent et al.

2008) multicenter study, depressed adolescents who failed to respond to an ade-
quate trial with an SSRI were randomly assigned to receive one of four interven-
tions using a balanced, two-by-two design: switch to another SSRI, switch to
venlafaxine, switch to another SSRI plus addition of CBT, or switch to venlafaxine
plus CBT. The combination of CBT plus medication was superior to medication
alone (option C is correct; options A, B, and D are incorrect). There were no dif-
ferences in outcome between switching to another SSRI or venlafaxine (options A
and B are incorrect), although there were more side effects in youth treated with
venlafaxine. (Chapter 13, Depressive and Disruptive Mood Dysregulation Dis-
orders/Treatment-Resistant Depression, p. 265)

13.2 A 17-year-old male presents with a low mood that has lasted for 1 month follow-
ing the sudden death of his mother in a car accident. Which of the following
would indicate that he may be experiencing a major depressive episode?

173
 A. He has thoughts about death that are primarily related to joining his deceased
mother.
B. His grief has decreased in intensity and occurs in waves that are associated
with thoughts of his mother.
C. He ruminates about the death of his mother and persistently feels as if he is
directly responsible for her death, contributing to feelings of worthlessness.
D. His feelings consist of emptiness and loss as a result of his mother’s death.

The correct response is option C: He ruminates about the death of his mother
and persistently feels as if he is directly responsible for her death, contributing
to feelings of worthlessness.

In distinguishing grief from a major depressive episode (MDE), it is useful to con-

sider that in grief the predominant affect is feelings of emptiness and loss (option D
is incorrect), while in MDE it is persistent depressed mood and the inability to an-
ticipate happiness or pleasure. The dysphoria in grief is likely to decrease in inten-
sity over days to weeks and occurs in waves, the so-called pangs of grief (option B
is incorrect). These waves tend to be associated with thoughts or reminders of the
deceased. The depressed mood of MDE is more persistent and not tied to specific
thoughts or preoccupations. The pain of grief may be accompanied by positive
emotions and humor that are uncharacteristic of the pervasive unhappiness and
misery characteristic of MDE. The thought content associated with grief generally
features a preoccupation with thoughts and memories of the deceased, rather than
the self-critical or pessimistic ruminations seen in MDE. In grief, self-esteem is gen-
erally preserved, whereas in MDE feelings of worthlessness and self-loathing are
common (option C is correct). If self-derogatory ideation is present in grief, it typi-
cally involves perceived failings vis-à-vis the deceased (e.g., not visiting frequently
enough, not telling the deceased how much he or she was loved). If a bereaved in-
dividual thinks about death and dying, such thoughts are generally focused on the
deceased and possibly about “joining” the deceased (option A is incorrect), whereas
in MDE such thoughts are focused on ending one’s own life because of feeling
worthless (option C is correct), undeserving of life, or unable to cope with the pain
of depression. (Chapter 13, Depressive and Disruptive Mood Dysregulation Dis-
orders/Depressive Disorders/Box 13–1, footnote 1, p. 247)

13.3 A 16-year-old youth presents with a moderate to severe depressive episode char-
acterized by low mood, hopelessness, insomnia, weight loss, decreased concen-
tration, and suicidal ideation that has been triggered as a result of conflictual
family interactions. Which of the following two psychotherapeutic modalities
have the greatest evidence base from randomized controlled trials (RCTs) for
treatment of depressed adolescents?

A. Interpersonal psychotherapy and psychodynamic psychotherapy.

B. Cognitive-behavioral therapy (CBT) and interpersonal psychotherapy.
C. Systemic behavioral family therapy and psychodynamic psychotherapy.
D. Cognitive-behavioral therapy and systemic behavioral family therapy.

174 | Depressive and Disruptive Mood Dysregulation Disorders—Answer Guide

 The correct response is option B: Cognitive-behavioral therapy (CBT) and inter-
personal psychotherapy.

Only CBT and interpersonal psychotherapy have evidence of efficacy from RCTs,
particularly for depressed adolescents (Weisz et al. 2006) (option B is correct).
Psychodynamic therapy is widely used in clinical practice despite lack of evi-
dence for efficacy (options A and C are incorrect). One RCT examined the impact
of family therapy and found that CBT was superior to systemic behavioral family
therapy in the short-term reduction of adolescent depression (options C and D are
incorrect). (Chapter 13, Depressive and Disruptive Mood Dysregulation Disor-
ders/Treatment/Acute Treatment/Psychotherapy, p. 258)

13.4 Which condition can coexist with a diagnosis of disruptive mood dysregulation
disorder (DMDD)?

A. Oppositional defiant disorder.

B. Attention-deficit/hyperactivity disorder.
C. Intermittent explosive disorder.
D. Bipolar disorder.

The correct response is option B: Attention-deficit/hyperactivity disorder.

DMDD cannot coexist with oppositional defiant disorder (option A is incorrect),

intermittent explosive disorder (option C is incorrect), or bipolar disorder (option D
is incorrect), though it can coexist with others, including major depressive disorder
(MDD), attention-deficit/hyperactivity disorder (option B is correct), conduct dis-
order, and substance use disorders. Individuals whose symptoms meet criteria
for both DMDD and oppositional defiant disorder should only be given the diag-
nosis of DMDD. If an individual has ever experienced a manic or hypomanic ep-
isode, the diagnosis of DMDD should not be assigned (Table 13–1). (Chapter 13,
Depressive and Disruptive Mood Dysregulation Disorders/Disruptive Mood
Dysregulation Disorder (DMDD)/Box 13–3, p. 267)

TABLE 13–1. DSM-5 Diagnostic Criteria for Disruptive Mood Dysregulation

Disorder

A. Severe recurrent temper outbursts manifested verbally (e.g., verbal rages) and/or behav-
iorally (e.g., physical aggression toward people or property) that are grossly out of propor-
tion in intensity or duration to the situation or provocation.
B. The temper outbursts are inconsistent with developmental level.
C. The temper outbursts occur, on average, three or more times per week.
D. The mood between temper outbursts is persistently irritable or angry most of the day,
nearly every day, and is observable by others (e.g., parents, teachers, peers).
E. Criteria A–D have been present for 12 or more months. Throughout that time, the individ-
ual has not had a period lasting 3 or more consecutive months without all of the symptoms
in Criteria A–D.

Depressive and Disruptive Mood Dysregulation Disorders—Answer Guide | 175

F. Criteria A and D are present in at least two of three settings (i.e., at home, at school, with
peers) and are severe in at least one of these.
G. The diagnosis should not be made for the first time before age 6 years or after age 18
years.
H. By history or observation, the age at onset of Criteria A–E is before 10 years.
I. There has never been a distinct period lasting more than 1 day during which the full symp-
tom criteria, except duration, for a manic or hypomanic episode have been met.
Note: Developmentally appropriate mood elevation, such as occurs in the context of a
highly positive event or its anticipation, should not be considered as a symptom of mania
or hypomania.
J. The behaviors do not occur exclusively during an episode of major depressive disorder
and are not better explained by another mental disorder (e.g., autism spectrum disorder,
posttraumatic stress disorder, separation anxiety disorder, persistent depressive disorder
[dysthymia]).
Note: This diagnosis cannot coexist with oppositional defiant disorder, intermittent ex-
plosive disorder, or bipolar disorder, though it can coexist with others, including major de-
pressive disorder, attention-deficit/hyperactivity disorder, conduct disorder, and substance
use disorders. Individuals whose symptoms meet criteria for both disruptive mood dys-
regulation disorder and oppositional defiant disorder should only be given the diagnosis
of disruptive mood dysregulation disorder. If an individual has ever experienced a manic or
hypomanic episode, the diagnosis of disruptive mood dysregulation disorder should not
be assigned.
K. The symptoms are not attributable to the physiological effects of a substance or to another
medical or neurological condition.

Source. Reprinted from American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders,
5th Edition. Arlington, VA, American Psychiatric Association, 2013. Copyright © 2013 American Psychiatric
Association. Used with permission.

13.5 A 14-year-old male presents with low mood and irritability for the past 4 months
with symptoms of somatic complaints, excessive worries about his health, insom-
nia, low energy, poor concentration, suicidal ideation, and low self-esteem. Which
of the following would be the most appropriate diagnosis?

A. Major depressive disorder (MDD) with mixed features.

B. MDD with anxious distress.
C. Persistent depressive disorder.
D. MDD with atypical features.

The correct response is option B: MDD with anxious distress.

Subtypes of MDD have prognostic and treatment implications. DSM-5 added a

new specifier with mixed features to denote the presence of at least three manic
symptoms that are insufficient to satisfy criteria for a manic or hypomanic epi-
sode (option A is incorrect). To emphasize the presence of anxiety and because co-
morbidity with anxiety predicts better response to the combination of cognitive-
behavioral therapy plus medication versus medication alone (Asarnow et al.
2009), the with anxious distress specifier was added (option B is correct). MDD can
be manifested with atypical symptoms such as increased reactivity to rejection, leth-

176 | Depressive and Disruptive Mood Dysregulation Disorders—Answer Guide

 argy (leaden paralysis), increased appetite, craving for carbohydrates, and hyper-
somnia (option D is incorrect). In persistent depressive disorder, depressed mood
occurs for at least 2 years (option C is incorrect). (Chapter 13, Depressive and
Disruptive Mood Dysregulation Disorders/Depressive Disorders/Clinical De-
scription, pp. 247–249)

References
Asarnow JR, Emslie G, Clarke G, et al: Treatment of selective serotonin reuptake inhibitor-resistant
depression in adolescents: predictors and moderators of treatment response. J Am Acad Child
Adolesc Psychiatry 48(3):330–339, 2009 19182688
Brent D, Emslie G, Clarke G, et al: Switching to another SSRI or to venlafaxine with or without cog-
nitive behavioral therapy for adolescents with SSRI-resistant depression: the TORDIA ran-
domized controlled trial. JAMA 299(8):901–913, 2008 18314433
Weisz JR, McCarty CA, Valeri SM: Effects of psychotherapy for depression in children and adoles-
cents: a meta-analysis. Psychol Bull 132(1):132–149, 2006 16435960

Depressive and Disruptive Mood Dysregulation Disorders—Answer Guide | 177

 C H A P T E R 1 4

Bipolar Disorder
14.1 Which of the following DSM-IV Criterion B symptoms has now been moved to
the DSM-5 Criterion A of “abnormally and persistently elevated, expansive, or ir-
ritable mood”?

A. Inflated self-esteem or grandiosity.

B. Decreased need for sleep.
C. Persistently increased activity or energy.
D. Flight of ideas or subjective experiences that thoughts are racing.

The correct response is option C: Persistently increased activity or energy.

Changes in the mania criteria in DSM-5 (American Psychiatric Association 2013)

include the addition of “abnormally and persistently increased activity or energy”
to the previous edition’s Criterion A (option C is correct). Inflated self-esteem or
grandiosity, decreased need for sleep, and flight of ideas remain under Criterion B
(options A, B, and D are incorrect) (Table 14–1). (Chapter 14, Bipolar Disorder/
Definition, Box 14–1, pp. 277–278)

TABLE 14–1. DSM-5 Diagnostic Criteria for Manic Episode (excerpted from
Bipolar I Disorder)

For a diagnosis of bipolar I disorder, it is necessary to meet the following criteria for a
manic episode. The manic episode may have been preceded by and may be followed by
hypomanic or major depressive episodes.

Manic Episode
A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood and
abnormally and persistently increased activity or energy, lasting at least 1 week and pres-
ent most of the day, nearly every day (or any duration if hospitalization is necessary).
B. During the period of mood disturbance and increased energy or activity, three (or more)
of the following symptoms (four if the mood is only irritable) are present to a significant de-
gree and represent a noticeable change from usual behavior:
1. Inflated self-esteem or grandiosity.
2. Decreased need for sleep (e.g., feels rested after only 3 hours of sleep).
3. More talkative than usual or pressure to keep talking.

179
 4. Flight of ideas or subjective experience that thoughts are racing.
5. Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stim-
uli), as reported or observed.
6. Increase in goal-directed activity (either socially, at work or school, or sexually) or psy-
chomotor agitation (i.e., purposeless non-goal-directed activity).
7. Excessive involvement in activities that have a high potential for painful consequences
(e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business
investments).
C. The mood disturbance is sufficiently severe to cause marked impairment in social or oc-
cupational functioning or to necessitate hospitalization to prevent harm to self or others,
or there are psychotic features.
D. The episode is not attributable to the physiological effects of a substance (e.g., a drug of
abuse, a medication, other treatment) or to another medical condition.
Note: A full manic episode that emerges during antidepressant treatment (e.g., medica-
tion, electroconvulsive therapy) but persists at a fully syndromal level beyond the physio-
logical effect of that treatment is sufficient evidence for a manic episode and, therefore, a
bipolar I diagnosis.
Note: Criteria A–D constitute a manic episode. At least one lifetime manic episode is re-
quired for the diagnosis of bipolar I disorder.

Source. Reprinted from American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders,
5th Edition, Arlington, VA, American Psychiatric Association, 2013. Copyright © 2013 American Psychiatric
Association. Used with permission.

14.2 Which of the following is the most common comorbid disorder in children with
mania?

A. Autism spectrum disorder.

B. Cannabis use disorder.
C. Alcohol use disorder.
D. Attention-deficit/hyperactivity disorder (ADHD).

The correct response is option D: Attention-deficit/hyperactivity disorder

(ADHD).

Children with symptoms that meet criteria for mania almost invariably qualify
for at least one other disorder. The most common simultaneous comorbidities
(ADHD, oppositional defiant disorder, conduct disorder, anxiety) occur during
mania, and it may be difficult to distinguish these comorbidities from mania with-
out a careful and detailed history. ADHD, which begins prior to bipolar disorder,
may be found in up to 90% of prepubertal children and about half of adolescents
with bipolar disorder (option D is correct). About 20% of children diagnosed with
mania also have comorbid autism spectrum disorder (option A is incorrect). Sub-
stance and alcohol abuse are common comorbidities in adolescents with bipolar
disorder (options B and C are incorrect). Cannabis abuse increases rates of psycho-
sis in general. (Chapter 14, Bipolar Disorder/Comorbidity, pp. 287–288)

180 | Bipolar Disorder—Answer Guide

14.3 Which of the following rates most accurately represents the risk of mania in high-
risk offspring in adulthood?

A. 60%.
B. 5%.
C. 35%.
D. 20%.

The correct response is option B: 5%.

Rates of mania in high-risk offspring who have been followed into adulthood
vary from 2% to 7% (option B is correct); rates of bipolar spectrum disorder are as
high as 20%. Twin studies of adults suggest that genetic influences explain ap-
proximately 60%–93% of the variance in bipolar disorder, while shared and
unique environmental factors account for 30%–40% and 10%–21%, respectively.
(Chapter 14, Bipolar Disorder/Etiology, Mechanisms, and Risk Factors, p. 288)

14.4 Which of the following is associated with a better prognosis following an episode
of mania in youth?

A. Older age at onset of mania.

B. Higher rates of comorbid conditions.
C. History of physical or sexual abuse.
D. Higher rates of psychiatric disorders in parents.

The correct response is option A: Older age at onset of mania.

In the Course of Bipolar Youth sample of patients over age 8 years, the “predom-
inantly euthymic” group, compared with the more chronic group, was older at
first symptoms and first episode and less likely to have experienced associated
depressive behaviors such as self-injurious and suicidal behavior (Birmaher et al.
2014) (option A is correct). Their condition overall was less complicated, with lower
rates of comorbid attention-deficit/hyperactivity disorder and anxiety (option B
is incorrect). Rates of psychiatric disorders in their parents were lower (option D
is incorrect), and rates of prior physical and sexual abuse were lower (option C is in-
correct). (Chapter 14, Bipolar Disorder/Age at Onset, Course, and Prognosis, p. 289)

14.5 Which of the following medications has shown the largest effect for the acute
treatment of mania/mixed mania in children and adolescents?

A. Lithium.
B. Divalproex.
C. Risperidone.
D. Oxcarbazepine.

The correct response is option C: Risperidone.

Bipolar Disorder—Answer Guide | 181

 The results from placebo-controlled trials of atypical antipsychotics for acute ma-
nia/mixed mania show a larger effect size than for mood stabilizers (option C is
correct). Although divalproex has a U.S. Food and Drug Administration treat-
ment indication for mania in adults, its efficacy in bipolar youth is less robust (op-
tion B is incorrect). Other anticonvulsants—topiramate and oxcarbazepine—have
not been found to be significantly better than placebo (Wagner et al. 2009) (option
D is incorrect). In the Treatment of Early Age Mania study (Geller et al. 2012), pa-
tients were randomly assigned to receive risperidone, lithium, or divalproex. In
this study, the lithium response rate was 35.6%, the atypical antipsychotic response
rate was 68.5%, and the divalproex response rate was 40% (options A and B are
incorrect). (Chapter 14, Bipolar Disorder/Treatment/Pharmacological Treatment,
pp. 294–296)

References
American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 5th Edi-
tion. Arlington, VA, American Psychiatric Association, 2013
Birmaher B, Gill MK, Axelson DA, et al: Longitudinal trajectories and associated baseline predic-
tors in youths with bipolar spectrum disorders. Am J Psychiatry 171(9):990–999, 2014
Geller B, Luby JL, Joshi P, et al: A randomized controlled trial of risperidone, lithium, or divalproex
sodium for initial treatment of bipolar I disorder, manic or mixed phase, in children and ad-
olescents. Arch Gen Psychiatry 69(5): 515–528, 2012 22213771
Wagner KD, Redden L, Kowatch RA, et al: A double-blind, randomized, placebo-controlled trial
of divalproex extended-release in the treatment of bipolar disorder in children and adoles-
cents. J Am Acad Child Adolesc Psychiatry 48(5):519–532, 2009 19325497

182 | Bipolar Disorder—Answer Guide

 C H A P T E R 1 5

Anxiety Disorders

15.1 A 16-year-old reports increased anxiety for the last 6 months in anticipation of
his upcoming second attempt on the college entrance examination, scheduled in
2 days. He has increased difficulty falling asleep, has felt more on edge, and wor-
ries what his peers think of him. He also worries about getting into college, his
health, and the health of his family. This teen is struggling with which of the fol-
lowing issues?

A. Generalized anxiety disorder.

B. Specific phobia.
C. Social anxiety disorder.
D. Separation anxiety disorder.

The correct response is option A: Generalized anxiety disorder.

Generalized anxiety disorder is characterized by excessive and uncontrollable

anxiety and worry (apprehensive expectation) regarding numerous situations or
activities, occurring most days for at least 6 months (option A is correct). Specific
phobia is characterized by marked fear or anxiety about a specific object or situa-
tion (option B is incorrect). Social anxiety disorder is characterized by a marked,
intense, and consistent fear or anxiety that occurs in one or more social situations
in which the individual may be scrutinized by others (option C is incorrect). Sep-
aration anxiety disorder is diagnosed when a child demonstrates developmentally
inappropriate distress associated with separation from a primary caregiver (op-
tion D is incorrect). (Chapter 15, Anxiety Disorders/Diagnostic Criteria and Ad-
ditional Features, pp. 306–309)

15.2 Which of the following medications is considered the first-line psychopharmaco-

logical treatment for preschool-age children with separation anxiety disorder,
generalized anxiety disorder, selective mutism, or specific phobia after a failed
12-week trial of psychotherapy?

A. Paroxetine.
B. Imipramine.

183
 C. Fluoxetine.
D. Clonazepam.

The correct response is option C: Fluoxetine.

The American Academy of Child and Adolescent Psychiatry Preschool Psycho-

pharmacology Working Group developed recommendations for psychopharma-
cological treatment in young children (Gleason et al. 2007). The algorithm for
anxiety disorders included separation anxiety disorder, generalized anxiety dis-
order, selective mutism, and specific phobia. Initially, psychotherapy for a minimum
of 12 weeks is recommended. If psychotherapy alone is not effective, fluoxetine is
the first-choice medication, in liquid form, starting at very low doses (1 mg) and mon-
itored closely (option C is correct). If an adequate trial of fluoxetine is not success-
ful, switching to another selective serotonin reuptake inhibitor is recommended.
Paroxetine, α-agonists, and tricyclic antidepressants (e.g., imipramine) were not
recommended (options A and B are incorrect). Benzodiazepines (e.g., clonazepam)
were listed under “not-endorsed practices” for preschoolers, except for extreme
anxiety for medical or dental procedures (option D is incorrect). (Chapter 15, Anx-
iety Disorders/Pharmacological Treatments/Pharmacological Treatment of Young
Children With Anxiety Disorders, pp. 334–335)

15.3 A 7-year-old boy worries that his mother will die while he is in school or that he
will get lost and never see his mother again. The boy refuses to attend school, is
often sick in the nurse’s office when he is in school, and refuses to go for sleepovers
at friends’ and relatives’ houses without his mother. This presentation is most
consistent with which of the following disorders?

A. Social anxiety disorder.

B. Separation anxiety disorder.
C. Generalized anxiety disorder.
D. Selective mutism.

The correct response is option B: Separation anxiety disorder.

Children with separation anxiety disorder often report fearful thoughts related to
anxiety-provoking situations (e.g., going to school, being away from the parent,
attending sleepovers). Common anxious thoughts include “Mom will forget to
pick me up from school”; “Mom will die when we are not together and I will
never see her again”; and “I will get lost and never be able to see Mom again.” As
a result of anxious thoughts about separation, children change their behavior to
prevent separation from their parents (e.g., school refusal, unwillingness to leave
parents to go to a friend’s house) (option B is correct).
Social anxiety disorder is characterized by a marked, intense, and consistent
fear or anxiety that occurs in one or more social situations in which the individual
may be scrutinized by others (option A is incorrect). Generalized anxiety disorder
is characterized by excessive and uncontrollable anxiety and worry (apprehensive

184 | Anxiety Disorders—Answer Guide

 expectation) regarding numerous situations or activities, occurring most days for
at least 6 months (option C is incorrect). Children with selective mutism are unable
to speak in certain social situations (e.g., at school) despite an established capacity
to speak in other situations (e.g., at home) (option D is incorrect). (Chapter 15, Anx-
iety Disorders/Applications of CBT and Other Interventions for Specific Anxiety
Disorders and School Refusal/Separation Anxiety Disorder, pp. 327–328; Diag-
nostic Criteria and Additional Features, pp. 306–310)

15.4 A 15-year-old girl has had school refusal for the last 7 months because she is
scared to leave her home, to be in crowded places or wide-open areas, and to ride
buses and trains with or without her parents. Which of the following diagnoses is
most consistent with this presentation?

A. Social anxiety disorder.

B. Separation anxiety disorder.
C. Generalized anxiety disorder.
D. Agoraphobia.

The correct response is option D: Agoraphobia.

Agoraphobia involves marked fear or anxiety about two (or more) of the follow-
ing situations: 1) using public transportation (e.g., automobiles, buses, trains,
ships, planes); 2) being in open spaces (e.g., parking lots, market places, bridges);
3) being in enclosed places (e.g., shops, theaters, cinemas); 4) standing in line or
being in a crowd; or 5) being outside of the home alone (option D is correct). Social
anxiety disorder is characterized by a marked, intense, and consistent fear or anxi-
ety that occurs in one or more social situations in which the individual may be scru-
tinized by others (option A is incorrect). Separation anxiety disorder is diagnosed
when the child demonstrates developmentally inappropriate distress associated
with separation from a primary caregiver (option B is incorrect). Generalized anxi-
ety disorder is characterized by excessive and uncontrollable anxiety and worry
(apprehensive expectation) regarding numerous situations or activities, occurring
most days for at least 6 months (option C is incorrect). (Chapter 15, Anxiety Dis-
orders/Diagnostic Criteria and Additional Features, pp. 306–309)

15.5 Which of the following psychotherapies has received the most evidence-based
support for treatment of a broad range of anxiety disorders in children and ado-
lescents?

A. Psychodynamic psychotherapy.
B. Exposure-based cognitive-behavioral therapy (CBT).
C. Parent-Child Interaction Therapy.
D. Family systems approach.

The correct response is option B: Exposure-based cognitive-behavioral therapy

(CBT).

Anxiety Disorders—Answer Guide | 185

 Among the psychotherapies, exposure-based CBT has received the most empiri-
cal support from randomized controlled studies for the treatment of anxiety dis-
orders in children and adolescents and is currently the psychotherapy of choice
for this population (option B is correct). Psychodynamic psychotherapy has been
used in the clinical treatment of anxiety disorders in children and adolescents, but
empirical evidence regarding efficacy or effectiveness is very limited (option A
is incorrect). Parent-Child Interaction Therapy is empirically supported as a treat-
ment for children with disruptive behavior disorders and has been adapted to be
used in the treatment of young children with separation anxiety disorder (option
C is incorrect). Psychotherapeutic treatments aimed at school refusal are primar-
ily cognitive-behavioral combined with a family systems approach that incorpo-
rates relaxation training, cognitive modification, social skills training, exposure-
based activities, and contracting and contingency management (option D is incor-
rect). (Chapter 15, Anxiety Disorders/Treatment/Psychotherapeutic Treatments,
pp. 324–328)

Reference
Gleason MM, Egger HL, Emslie GJ, et al: Psychopharmacological treatment for very young chil-
dren: contexts and guidelines. J Am Acad Child Adolesc Psychiatry 46(12):1532–1572, 2007
18030077

186 | Anxiety Disorders—Answer Guide

 C H A P T E R 1 6

Posttraumatic Stress
Disorder and Persistent
Complex Bereavement
Disorder
16.1 According to DSM-5 criteria, exposure to a traumatic event by what means is con-
sidered insufficient for the diagnosis of posttraumatic stress disorder (PTSD) in
children 6 years and younger?

A. Directly experiencing the traumatic event.

B. Learning that a traumatic event occurred to a parent or caregiver.
C. Witnessing a traumatic event in electronic media, television, movies, or pic-
tures.
D. Witnessing a traumatic event occurring to a parent or caregiver.

The correct response is option C: Witnessing a traumatic event in electronic me-

dia, television, movies, or pictures.

DSM-5 criteria (American Psychiatric Association 2013) for the diagnosis of PTSD
in children 6 years and younger (Table 16–1) include exposure to actual or threat-
ened death, serious injury, or sexual violence by one (or more) of three ways (Cri-
terion A): directly experiencing the traumatic event(s) (option A is incorrect);
witnessing the event(s) as it occurred to others, especially primary caregivers (op-
tion D is incorrect); or learning that the traumatic event(s) occurred to a parent or
caregiving figure (option B is incorrect). DSM-5 criteria stipulate that witnessing
does not include events witnessed only in electronic media, television, movies, or
pictures (option C is correct). (Chapter 16, Posttraumatic Stress Disorder and
Persistent Complex Bereavement Disorder/Box 16–1, pp. 347–348)

187
TABLE 16–1. DSM-5 Diagnostic Criteria for Posttraumatic Stress Disorder

Posttraumatic Stress Disorder

Note: The following criteria apply to adults, adolescents, and children older than 6 years. For
children 6 years and younger, see corresponding criteria below.
A. Exposure to actual or threatened death, serious injury, or sexual violence in one (or more)
of the following ways:
1. Directly experiencing the traumatic event(s).
2. Witnessing, in person, the event(s) as it occurred to others.
3. Learning that the traumatic event(s) occurred to a close family member or close friend.
In cases of actual or threatened death of a family member or friend, the event(s) must
have been violent or accidental.
4. Experiencing repeated or extreme exposure to aversive details of the traumatic
event(s) (e.g., first responders collecting human remains; police officers repeatedly ex-
posed to details of child abuse).
Note: Criterion A4 does not apply to exposure through electronic media, television,
movies, or pictures, unless this exposure is work related.
B. Presence of one (or more) of the following intrusion symptoms associated with the trau-
matic event(s), beginning after the traumatic event(s) occurred:
1. Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s).
Note: In children older than 6 years, repetitive play may occur in which themes or as-
pects of the traumatic event(s) are expressed.
2. Recurrent distressing dreams in which the content and/or affect of the dream are relat-
ed to the traumatic event(s).
Note: In children, there may be frightening dreams without recognizable content.
3. Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the
traumatic event(s) were recurring. (Such reactions may occur on a continuum, with the
most extreme expression being a complete loss of awareness of present surroundings.)
Note: In children, trauma-specific reenactment may occur in play.
4. Intense or prolonged psychological distress at exposure to internal or external cues
that symbolize or resemble an aspect of the traumatic event(s).
5. Marked physiological reactions to internal or external cues that symbolize or resemble
an aspect of the traumatic event(s).
C. Persistent avoidance of stimuli associated with the traumatic event(s), beginning after the
traumatic event(s) occurred, as evidenced by one or both of the following:
1. Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or
closely associated with the traumatic event(s).
2. Avoidance of or efforts to avoid external reminders (people, places, conversations, ac-
tivities, objects, situations) that arouse distressing memories, thoughts, or feelings
about or closely associated with the traumatic event(s).
D. Negative alterations in cognitions and mood associated with the traumatic event(s), be-
ginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more)
of the following:
1. Inability to remember an important aspect of the traumatic event(s) (typically due to disso-
ciative amnesia and not to other factors such as head injury, alcohol, or drugs).

188 | PTSD and Persistent Complex Bereavement Disorder—Answer Guide

 2. Persistent and exaggerated negative beliefs or expectations about oneself, others, or
the world (e.g., “I am bad,” “No one can be trusted,” “The world is completely danger-
ous,” “My whole nervous system is permanently ruined”).
3. Persistent, distorted cognitions about the cause or consequences of the traumatic
event(s) that lead the individual to blame himself/herself or others.
4. Persistent negative emotional state (e.g., fear, horror, anger, guilt, or shame).
5. Markedly diminished interest or participation in significant activities.
6. Feelings of detachment or estrangement from others.
7. Persistent inability to experience positive emotions (e.g., inability to experience hap-
piness, satisfaction, or loving feelings).
E. Marked alterations in arousal and reactivity associated with the traumatic event(s), begin-
ning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of
the following:
1. Irritable behavior and angry outbursts (with little or no provocation) typically expressed as
verbal or physical aggression toward people or objects.
2. Reckless or self-destructive behavior.
3. Hypervigilance.
4. Exaggerated startle response.
5. Problems with concentration.
6. Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep).
F. Duration of the disturbance (Criteria B, C, D, and E) is more than 1 month.
G. The disturbance causes clinically significant distress or impairment in social, occupation-
al, or other important areas of functioning.
H. The disturbance is not attributable to the physiological effects of a substance (e.g., medi-
cation, alcohol) or another medical condition.
Specify whether:
With dissociative symptoms: The individual’s symptoms meet the criteria for posttrau-
matic stress disorder, and in addition, in response to the stressor, the individual experienc-
es persistent or recurrent symptoms of either of the following:
1. Depersonalization: Persistent or recurrent experiences of feeling detached from, and as
if one were an outside observer of, one’s mental processes or body (e.g., feeling as though
one were in a dream; feeling a sense of unreality of self or body or of time moving slowly).
2. Derealization: Persistent or recurrent experiences of unreality of surroundings (e.g.,
the world around the individual is experienced as unreal, dreamlike, distant, or dis-
torted).
Note: To use this subtype, the dissociative symptoms must not be attributable to the
physiological effects of a substance (e.g., blackouts, behavior during alcohol intoxica-
tion) or another medical condition (e.g., complex partial seizures).
Specify if:
With delayed expression: If the full diagnostic criteria are not met until at least 6 months after
the event (although the onset and expression of some symptoms may be immediate).

Posttraumatic Stress Disorder for Children 6 Years and Younger

A. In children 6 years and younger, exposure to actual or threatened death, serious injury, or
sexual violence in one (or more) of the following ways:

PTSD and Persistent Complex Bereavement Disorder—Answer Guide | 189

 1. Directly experiencing the traumatic event(s).
2. Witnessing, in person, the event(s) as it occurred to others, especially primary care-
givers.
Note: Witnessing does not include events that are witnessed only in electronic media,
television, movies, or pictures.
3. Learning that the traumatic event(s) occurred to a parent or caregiving figure.
B. Presence of one (or more) of the following intrusion symptoms associated with the trau-
matic event(s), beginning after the traumatic event(s) occurred:
1. Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s).
Note: Spontaneous and intrusive memories may not necessarily appear distressing
and may be expressed as play reenactment.
2. Recurrent distressing dreams in which the content and/or affect of the dream are re-
lated to the traumatic event(s).
Note: It may not be possible to ascertain that the frightening content is related to
the traumatic event.
3. Dissociative reactions (e.g., flashbacks) in which the child feels or acts as if the trau-
matic event(s) were recurring. (Such reactions may occur on a continuum, with the most
extreme expression being a complete loss of awareness of present surroundings.)
Such trauma-specific reenactment may occur in play.
4. Intense or prolonged psychological distress at exposure to internal or external cues that
symbolize or resemble an aspect of the traumatic event(s).
5. Marked physiological reactions to reminders of the traumatic event(s).
C. One (or more) of the following symptoms, representing either persistent avoidance of stim-
uli associated with the traumatic event(s) or negative alterations in cognitions and mood
associated with the traumatic event(s), must be present, beginning after the event(s) or
worsening after the event(s):
Persistent Avoidance of Stimuli
1. Avoidance of or efforts to avoid activities, places, or physical reminders that arouse recol-
lections of the traumatic event(s).
2. Avoidance of or efforts to avoid people, conversations, or interpersonal situations that
arouse recollections of the traumatic event(s).
Negative Alterations in Cognitions
3. Substantially increased frequency of negative emotional states (e.g., fear, guilt, sad-
ness, shame, confusion).
4. Markedly diminished interest or participation in significant activities, including constric-
tion of play.
5. Socially withdrawn behavior.
6. Persistent reduction in expression of positive emotions.
D. Alterations in arousal and reactivity associated with the traumatic event(s), beginning or
worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the fol-
lowing:
1. Irritable behavior and angry outbursts (with little or no provocation) typically expressed as
verbal or physical aggression toward people or objects (including extreme temper tan-
trums).
2. Hypervigilance.

190 | PTSD and Persistent Complex Bereavement Disorder—Answer Guide

 3. Exaggerated startle response.
4. Problems with concentration.
5. Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep).
E. The duration of the disturbance is more than 1 month.
F. The disturbance causes clinically significant distress or impairment in relationships with
parents, siblings, peers, or other caregivers or with school behavior.
G. The disturbance is not attributable to the physiological effects of a substance (e.g., medi-
cation or alcohol) or another medical condition.
Specify whether:
With dissociative symptoms: The individual’s symptoms meet the criteria for posttrau-
matic stress disorder, and the individual experiences persistent or recurrent symptoms of
either of the following:
1. Depersonalization: Persistent or recurrent experiences of feeling detached from, and
as if one were an outside observer of, one’s mental processes or body (e.g., feeling as
though one were in a dream; feeling a sense of unreality of self or body or of time mov-
ing slowly).
2. Derealization: Persistent or recurrent experiences of unreality of surroundings (e.g.,
the world around the individual is experienced as unreal, dreamlike, distant, or distorted).
Note: To use this subtype, the dissociative symptoms must not be attributable to the
physiological effects of a substance (e.g., blackouts) or another medical condition (e.g.,
complex partial seizures).
Specify if:
With delayed expression: If the full diagnostic criteria are not met until at least 6 months
after the event (although the onset and expression of some symptoms may be immediate).

Source. Reprinted from American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders,
5th Edition. Arlington, VA, American Psychiatric Association, 2013. Copyright © 2013 American Psychiatric
Association. Used with permission.

16.2 How do children and adults differ in regard to DSM-5 Criterion B for posttraumatic
stress disorder (PTSD) (intrusive symptoms)?

A. Intrusive memories may not appear distressing in children and may be ex-
pressed in play.
B. Distressing dreams in children very closely resemble the actual trauma.
C. Children may intrude on others by exhibiting extreme temper tantrums.
D. Children usually do not exhibit physiological reactions to trauma.

The correct response is option A: Intrusive memories may not appear distress-
ing in children and may be expressed in play.

DSM-5 specifies ways in which PTSD may differ in young children as compared
to adults. For example, spontaneous and intrusive memories may not necessarily
appear distressing and may be expressed as play reenactment (option A is correct).
In children, it may not be possible to ascertain that the frightening content of
dreams is related to the traumatic event (option B is incorrect). Extreme temper tan-

PTSD and Persistent Complex Bereavement Disorder—Answer Guide | 191

 trums may be a symptom of alterations in arousal and reactivity in children, but
these are not considered intrusive symptoms and are listed in Criterion D (option
C is incorrect). Children may experience marked physiological reactions to re-
minders of the traumatic event (option D is incorrect). (Chapter 16, Posttraumatic
Stress Disorder and Persistent Complex Bereavement Disorder/Box 16–1, p. 348)

16.3 From whom should information typically be gathered when assessing children for
posttraumatic stress disorder (PTSD)?

A. The child.
B. The caretaker.
C. The child and caretaker.
D. The child’s teacher.

The correct response is option C: The child and caretaker.

When assessing children for PTSD or any other psychiatric disorder, the clinician
should gather information from multiple informants. For very young children, in-
formation from the child may be primarily observational and subjective, and a
complete evaluation requires gathering information from the parents as well as
the child (option C is correct). Information from either the child or caretaker alone
may be insufficient to make the diagnosis (option A and B are incorrect). Because
of privacy concerns, the family may not want the school to know the child is re-
ceiving an evaluation, and they will need to be assured about confidentiality, if
this is appropriate. In some cases it may be necessary or possible to complete the
evaluation without receiving teacher reports (option D is incorrect). (Chapter 16,
Posttraumatic Stress Disorder and Persistent Complex Bereavement Disorder,
p. 354)

16.4 How is persistent complex bereavement disorder distinguished from normal grief
in children?

A. The grief is severe and persists for more than 6 months after the death.
B. The child fails to accept the permanence of the death.
C. The cause of the death was suicide or homicide.
D. The symptoms are consistent with cultural or religious norms.

The correct response is option A: The grief is severe and persists for more than
6 months after the death.

The presence of severe grief reactions persisting for at least 6 months after the death
suggests the possibility of persistent complex bereavement disorder (option A is
correct). Depending on the age of the child, failure to accept the permanence of
the death may be developmentally appropriate and consistent with normal grief
(option B is incorrect). The specifier “with traumatic bereavement” may be used
in cases of suicide or homicide, but persistent complex bereavement disorder may
develop following deaths from other causes (option C is incorrect). Symptoms

192 | PTSD and Persistent Complex Bereavement Disorder—Answer Guide

 consistent with cultural or religious norms suggest normal grief, and should be
considered when making a diagnosis (option D is incorrect). (Chapter 16, Post-
traumatic Stress Disorder and Persistent Complex Bereavement Disorder/Box
16–2, pp. 349–350; Clinical Evaluation/Differential Diagnosis, pp. 355–356)

16.5 When should medication be considered prior to psychotherapy in the treatment of

posttraumatic stress disorder (PTSD) in children?

A. When PTSD is the sole diagnosis without comorbidity.

B. When there are no safety concerns regarding the medications.
C. When the child is unable to function.
D. Medications should generally be considered as a first-line treatment for PTSD.

The correct response is option C: When the child is unable to function.

Among the available treatments for childhood PTSD, there is more evidence for
trauma-focused psychotherapy (i.e., therapies that specifically address and focus
on children’s traumatic experiences) than for pharmacotherapies. Therefore, in
most cases, clinicians should provide children with evidence-based psychother-
apy prior to starting medication unless there is a compelling reason to do other-
wise (option D is incorrect). In some cases, there may be justification for starting
medication immediately; for example, there may be a comorbid condition for
which there is a proven pharmacological treatment (option A is incorrect), the
child may be so dysregulated or dangerous to self or others that a medication is
required for immediate safety (option B is incorrect), or the child is unable to func-
tion without the immediate addition of medication for another reason (e.g., sleep
is severely impaired and the condition has not responded to reasonable psycho-
social interventions) (option C is correct). (Chapter 16, Posttraumatic Stress Dis-
order and Persistent Complex Bereavement Disorder/Treatment, p. 356)

16.6 Which type of individual psychotherapy has the strongest evidence base for ef-
fectively treating posttraumatic stress disorder (PTSD) in older children?

A. Trauma-focused cognitive-behavioral therapy (CBT).

B. Child–parent psychotherapy.
C. Narrative Exposure Therapy for Children (KidNET).
D. Trauma systems therapy.

The correct response is option A: Trauma-focused cognitive-behavioral therapy

(CBT).

Trauma-focused CBT has the strongest evidence base for effectively treating chil-
dren who have PTSD (option A is correct; options B, C, and D are incorrect). Child–
parent psychotherapy is a relationship-based model delivered in joint treatment
sessions for a traumatized young child and his or her parent, often when the parent
has also experienced trauma. Narrative Exposure Therapy for Children (KidNET)
is a structured treatment for children exposed to war and refugee experiences.

PTSD and Persistent Complex Bereavement Disorder—Answer Guide | 193

 Trauma systems therapy combines individual treatment with a systems-based
approach that may include inpatient hospitalization, medications, home-based
interventions, and liaison with other professionals. (Chapter 16, Posttraumatic
Stress Disorder and Persistent Complex Bereavement Disorder/Treatment/Psy-
chotherapeutic Treatments, pp. 356–360)

16.7 When psychopharmacological treatment is indicated, which of the following

medications may be considered first line in the treatment of posttraumatic stress
disorder (PTSD) in children?

A. Morphine.
B. Risperidone.
C. Prazosin.
D. Clonidine.

The correct response is option D: Clonidine.

Despite the failure of several randomized controlled treatment trials to document

that pharmacological agents effectively treat PTSD in the pediatric age group,
many medications are prescribed for children with PTSD symptoms (see Wilkin-
son and Carrion 2012). Small open trials have suggested the potential benefit of
selective serotonin reuptake inhibitors (e.g., Seedat et al. 2002), propranolol (Fam-
ularo et al. 1988), and clonidine (option D is correct) (Harmon and Riggs 1996;
Perry 1994) for treating childhood PTSD. A case report suggested the potential
benefit for prazosin for improving reexperiencing and hyperarousal symptoms
(option C is incorrect) (Strawn et al. 2009). Open trials have been conducted with
two additional medications, neither of which would typically be routinely pre-
scribed for traumatized children in outpatient settings. Saxe et al. (2001) con-
ducted a naturalistic study examining morphine doses for acutely burned children
who required hospitalization. These researchers documented a linear association
between mean morphine dosage (mg/kg/day) and 6-month reduction in PTSD
symptoms, after controlling for subjective experience of pain. Morphine would
likely be considered a first-line treatment for PTSD only among acutely injured or
possibly other acutely traumatized children seen in hospital settings (option A is
incorrect). An open trial using risperidone demonstrated remission from severe
PTSD symptoms in 13 of 18 boys (Horrigan and Barnhill 1999). This cohort had high
rates of serious comorbid conditions (e.g., bipolar disorder, attention-deficit/
hyperactivity disorder, aggression); such factors would need to be weighed carefully
when considering potential risks versus potential benefits of using atypical anti-
psychotic medications in children (option B is incorrect). (Chapter 16, Posttrau-
matic Stress Disorder and Persistent Complex Bereavement Disorder/Treatment/
Pharmacological Treatments, p. 360)

194 | PTSD and Persistent Complex Bereavement Disorder—Answer Guide

References
American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 5th Edi-
tion. Arlington, VA, American Psychiatric Association, 2013
Famularo R, Kinscherff R, Fenton T: Propranolol treatment for childhood posttraumatic stress dis-
order, acute type. A pilot study. Am J Dis Child 142(11):1244–1247, 1988 3177336
Harmon RJ, Riggs PD: Clonidine for posttraumatic stress disorder in preschool children. J Am
Acad Child Adolesc Psychiatry 35(9):1247–1249, 1996 8824068
Horrigan JP, Barnhill LJ: Risperidone and PTSD in boys. J Neuropsychiatry Clin Neurosci 11:126–
127, 1999
Perry BD: Neurobiological sequelae of childhood trauma: PTSD in children, in Catecholamine
Function in Posttraumatic Stress Disorder: Emerging Concepts. Edited by Murburg MM. Wash-
ington, DC, American Psychiatric Press, 1994, pp 223–255
Saxe G, Stoddard F, Courtney D, et al: Relationship between acute morphine and the course of
PTSD in children with burns. J Am Acad Child Adolesc Psychiatry 40(8):915–921, 2001
11501691
Seedat S, Stein DJ, Ziervogel C, et al: Comparison of response to selective serotonin reuptake in-
hibitor in children, adolescents, and adults with posttraumatic stress disorder. J Child Ado-
lesc Psychopharmacol 12(1):37–46, 2002 12014594
Strawn JR, Delbello MP, Geracioti TD: Prazosin treatment of an adolescent with posttraumatic
stress disorder. J Child Adolesc Psychopharmacol 19(5):599–600, 2009 19877989
Wilkinson JM, Carrion VG: Pharmacotherapy in pediatric PTSD: a developmentally focused re-
view of the evidence. Curr Psychopharmacol 1(3):252–270, 2012

PTSD and Persistent Complex Bereavement Disorder—Answer Guide | 195

 C H A P T E R 1 7

Obsessive-Compulsive
Disorder
17.1 Which of the following is true regarding epidemiological studies of obsessive-
compulsive disorder (OCD)?

A. More than 90% of cases of OCD have childhood onset.

B. OCD is characterized by two peaks of incidence, one occurring in adolescence
and another in early adulthood.
C. Prevalence of pediatric OCD is about 1%–2%, point prevalence 0.25%, and child-
hood onset occurs in about one-third to one-half of all cases.
D. Socioeconomic status and intelligence seem to not be associated with OCD in
youth.

The correct response is option C: Prevalence of OCD is about 1%–2%, point

prevalence 0.25%, and childhood onset occurs in about one-third to one-half of
all cases.

Prevalence rates of pediatric OCD are around 1%–2% in the United States and else-
where (Apter et al. 1996; Flament et al. 1988) (option C is correct). In the first epi-
demiological study of pediatric OCD (Flament et al. 1988), most subjects
identified through screening who were later diagnosed with OCD had been pre-
viously undiagnosed. In the British Child Mental Health Survey of more than 10,000
children and adolescents ages 5–15 years, the point prevalence was 0.25% (option
C is correct). Almost 90% of cases identified had been undetected and untreated.
In this study, lower socioeconomic status and lower intelligence quotient were as-
sociated with OCD in youth (Heyman et al. 2001) (option D is incorrect). There are
two peaks of incidence for OCD across the life span, one occurring in preadoles-
cent children and a later peak in early adult life (mean age of 21 years) (Geller et
al. 2001) (option B is incorrect). Childhood onset occurs in at least 30%–50% of
cases (Pauls et al. 1995) (option A is incorrect). (Chapter 17, Obsessive-Compul-
sive Disorder/Epidemiology, p. 368)

197
17.2 What distinguishes pediatric obsessive-compulsive disorder (OCD) from adult
OCD?

A. Adult OCD has a higher familial rate than pediatric OCD.

B. Pediatric OCD has a better prognosis.
C. Cases of pediatric OCD do not seem to be etiologically related to pediatric au-
toimmune neuropsychiatric disorders associated with streptococcal infection
(PANDAS).
D. Pediatric OCD generally has a pubertal age of inset.

The correct response is option B: Pediatric OCD has a better prognosis.

OCD in childhood is distinct in important ways from the disorder in adults. Pedi-
atric OCD generally has a prepubertal age at onset (option D is incorrect), is male
predominant, and is characterized by a distinct pattern of obsessive-compulsive
symptoms and psychiatric comorbidity. Relative to OCD beginning in adulthood,
pediatric OCD may in some cases be etiologically related to immune-mediated
pathology (e.g., PANDAS) (option C is incorrect). Additionally, pediatric OCD is
more highly familial and generally has a better prognosis (option A is incorrect;
option B is correct). The secretive nature of OCD symptoms and the isolated and
idiosyncratic functional deficits, which may be severe but domain-specific and vari-
able, contribute to OCD being underrecognized and underdiagnosed in youth.
(Chapter 17, Obsessive-Compulsive Disorder/Clinical Features, p. 367)

17.3 Which of the following is correct regarding pediatric obsessive-compulsive disorder

(OCD) and comorbid disorders?

A. Earlier age at onset for OCD predicts increased risk for anxiety disorders but
not attention-deficit/hyperactivity disorder (ADHD).
B. In pediatric OCD, psychotic disorders are associated with older age and mood
disorders with younger age.
C. Comorbid Tourette’s disorder is associated with an earlier age at onset and lower
chronological age.
D. In contrast to Tourette’s disorder alone, OCD with comorbid Tourette’s usually
does not show a remission of tics during adolescence.

The correct response is option C: Comorbid Tourette’s disorder is associated

with an earlier age at onset and lower chronological age.

Regardless of age at ascertainment, an earlier age at onset for OCD predicts in-
creased risk for ADHD and anxiety disorders (option A is incorrect). In contrast,
mood and psychotic disorders are associated with older age and are more preva-
lent in adolescent subjects with OCD (option B is incorrect). Tourette’s disorder is
associated with both age at onset (earlier onset is more likely to be associated with
comorbid Tourette’s disorder) and chronological age (adolescents usually show
remission of tics) (option C is correct; option D is incorrect). (Chapter 17, Obses-
sive-Compulsive Disorder/Comorbidity, p. 368)

198 | Obsessive-Compulsive Disorder—Answer Guide

17.4 What are key features of the frontostriatal model of obsessive-compulsive disor-
der (OCD)?

A. It is based on a hypothesis of decreased glutamate.

B. Major brain structures central to OCD include the orbitofrontal cortex, ante-
rior cingulate cortex, caudate, and thalamus.
C. In contrast to adults, pediatric OCD imaging studies detect structural abnor-
malities in the cingulate cortex, basal ganglia, and thalami.
D. Functional imaging studies prior to and following treatment have shown greater
results in children with OCD than in adults with OCD.

The correct response is option B: Major brain structures central to OCD include
the orbitofrontal cortex, anterior cingulate cortex, caudate, and thalamus.

The frontostriatal model of OCD hypothesizes that increased glutamate can result
from both the internal globus pallidus–substantia nigra pars reticulata interaction
with the thalamus and the interactions between the striatum and external globus
pallidus (Kalra and Swedo 2009) (option A is incorrect). Major brain structures
central to OCD include the orbitofrontal cortex, anterior cingulate cortex, caudate,
and thalamus (Pauls et al. 2014) (option B is correct). Pediatric imaging studies ap-
pear similar to those in adults, detecting structural abnormalities in the cingulate
cortex, basal ganglia, and thalami of pediatric OCD patients (Abramovitch et al.
2012) (option C is incorrect). A handful of functional imaging studies conducted
with children at rest and following treatment have yielded results compatible
with those in adults (option D is incorrect). (Chapter 17, Obsessive-Compulsive
Disorder/Pathophysiology, Mechanisms, and Risk Factors, pp. 369–370)

17.5 Which of the following is true about genetic and environmental factors in obses-
sive-compulsive disorder (OCD)?

A. According to twin studies, genetic factors are more important than unique en-
vironmental factors.
B. According to a sample study of female twin pairs, heritability was higher for
compulsions than obsessions.
C. Many to most cases of OCD arise without a positive family history of the dis-
order.
D. There does not seem to be a correlation between “normative” ritualistic behav-
iors in childhood and the subsequent onset of OCD.

The correct response is option C: Many to most cases of OCD arise without a
positive family history of the disorder.

Twin studies show that even among monozygotic twins, OCD is not fully concor-
dant. In a cross-cultural sample of 4,246 twin pairs (Hudziak et al. 2004), genetic
(45%–58%) and unique environmental (42%–55%) factors were almost equally
important (option A is incorrect). In a population sample of 527 female twin pairs
(Jonnal et al. 2000), heritability was 33% for obsessions and 26% for compulsions

Obsessive-Compulsive Disorder—Answer Guide | 199

 (option B is incorrect). Furthermore, a study of 4,662 pediatric twin pairs found a
moderate correlation (r=0.40) between “normative” ritualistic behaviors in child-
hood and subsequent onset of OCD, suggesting not only that such behaviors are
a potential risk factor for OCD onset but also that nonshared environmental fac-
tors can trigger the disorder (Pauls et al. 2014) (option D is incorrect). Clearly, non-
heritable etiological factors contribute to the risk of developing OCD as much as,
if not more than, genetic factors. In fact, many to most cases of OCD arise without
a positive family history of the disorder (option C is correct). (Chapter 17, Obses-
sive-Compulsive Disorder/Pathophysiology, Mechanisms, and Risk Factors/
Environmental Factors, pp. 371–372)

17.6 How much of the reduction in Children’s Yale-Brown Obsessive Compulsive

Scale (CY-BOCS) scores is thought to be clinically significant?

A. 50%–70% reduction.
B. 25%– 40% reduction.
C. Anything greater than a 5% reduction.
D. Anything greater than a 50% reduction.

The correct response is option B: 25%–40% reduction.

The CY-BOCS includes a checklist of more than 60 obsessions and compulsions

categorized by the predominant theme involved, such as contamination, hoard-
ing, washing, checking, and so forth. Scores of 8–15 are considered to represent
mild illness, 16–23 moderate illness, and ≥24 severe illness. Marked reductions in
time occupied by obsessions or compulsions are not reflected in a proportional
drop in scale scores. It is for this reason that a 25%–40% reduction in CY-BOCS scores
is considered a clinically significant response (option B is correct; options A, C,
and D are incorrect). (Chapter 17, Obsessive-Compulsive Disorder/Evaluation/
Making the Diagnosis, p. 374)

17.7 For diagnostic criteria for pediatric autoimmune neuropsychiatric disorders asso-
ciated with streptococcal infection (PANDAS) to be met, when does onset have to
occur?

A. Between ages 3 and 10 years.

B. Between ages 3 and 12 years, or Tanner I or II.
C. Before age 18 years.
D. Between ages 3 and 15 years, or Tanner I through IV.

The correct response is option B: Between ages 3 and 12, or Tanner I or II.

The following are the diagnostic criteria for PANDAS (Swedo et al. 1997):

1. Obsessive-compulsive disorder and/or a tic disorder.

2. Prepubertal onset between 3 and 12 years of age, or Tanner I or II (option B is
correct; options A, C, and D are incorrect).

200 | Obsessive-Compulsive Disorder—Answer Guide

 3. Episodic course (abrupt onset and/or exacerbations).
4. Symptom onset/exacerbations temporally related to documented GABHS
(group A β-hemolytic streptococcus) infections on two occasions.
5. Association with neurological abnormalities.

(Chapter 17, Obsessive-Compulsive Disorder/Pathophysiology, Mechanisms,

and Risk Factors/PANDAS and Pediatric Acute Neuropsychiatric Syndrome/
Table 17–1, p. 371)

17.8 How can symptoms of obsessive-compulsive disorder (OCD) be differentiated

from those of other disorders, such as autism spectrum disorder and psychotic
disorders?

A. Children with autism spectrum disorder often display discomfort when per-
forming repetitive activities, whereas those with OCD usually do not have dis-
cernible anxiety.
B. In children with OCD, insight usually varies with level of anxiety, whereas in
children with delusional thought, symptoms are often static.
C. The nature of obsessional ideation is less often odd and atypical in pediatric
patients with psychosis than in those with OCD.
D. Symptoms of autism spectrum disorder may be easily confused with OCD, es-
pecially in young children, and about 15% of children with OCD may also meet
criteria for autism spectrum disorder.

The correct response is option B: In children with OCD, insight usually varies
with level of anxiety, whereas in children with delusional thought, symptoms
are often static.

Core symptoms of autism spectrum disorder include stereotypic, repetitive be-

haviors and a restricted and narrow range of interests and activities that may eas-
ily be confused with OCD, especially in young children. A small percentage of
children with OCD (5%–7%) may also have symptoms that meet criteria for DSM-
IV Asperger’s syndrome or pervasive developmental disorder (Geller et al. 2001)
(option D is incorrect). In OCD, symptoms are ego-dystonic and are associated
with anxiety-driven obsessional fears. Children with pervasive developmental
disorder engage in repetitive behaviors with apparent gratification and will be-
come upset only when their preferred activities are interrupted. Left to their ritu-
als, they do not display anxiety or discomfort. While younger children with OCD
may not be able to articulate their concerns, evidence of anxiety is usually discern-
ible (option A is incorrect). If symptoms are typical of OCD (such as washing,
cleaning, or checking), one can infer obsessional concern. Another diagnostic di-
lemma occurs in the context of poor insight into obsessional ideas that merges
into overvalued ideation and even delusional thinking, suggesting psychosis. In
children with OCD, insight is not static but rather varies with anxiety level and is
best assessed when anxiety is at a minimum (option B is correct). The nature of
obsessional ideation in patients with psychosis is often atypical (e.g., a fear that

Obsessive-Compulsive Disorder—Answer Guide | 201

 he will turn into another person or that her parent has been replaced by an alien)
(option C is incorrect). (Chapter 17, Obsessive-Compulsive Disorder/Evalua-
tion/Differential Diagnosis, pp. 374–375)

References
Abramovitch A, Mittelman A, Henin A, et al: Neuroimaging and neuropsychological findings in
pediatric obsessive-compulsive disorder: a review and developmental considerations. Neu-
ropsychiatry 2(4):313–329, 2012
Apter A, Fallon TJ Jr, King RA, et al: Obsessive-compulsive characteristics: from symptoms to syn-
drome. J Am Acad Child Adolesc Psychiatry 35(7):907–912, 1996 8768350
Flament MF, Whitaker A, Rapoport JL, et al: Obsessive compulsive disorder in adolescence: an ep-
idemiological study. J Am Acad Child Adolesc Psychiatry 27(6):764–771, 1988 3264280
Geller DA, Biederman J, Faraone S, et al: Developmental aspects of obsessive compulsive disorder:
findings in children, adolescents, and adults. J Nerv Ment Dis 189(7):471–477, 2001 11504325
Heyman I, Fombonne E, Simmons H, et al: Prevalence of obsessive-compulsive disorder in the
British nationwide survey of child mental health. Br J Psychiatry 179:324–329, 2001 11581112
Hudziak JJ, Van Beijsterveldt CE, Althoff RR, et al: Genetic and environmental contributions to the
Child Behavior Checklist Obsessive-Compulsive Scale: a cross-cultural twin study. Arch Gen
Psychiatry 61(6):608–616, 2004 15184240
Jonnal AH, Gardner CO, Prescott CA, et al: Obsessive and compulsive symptoms in a general pop-
ulation sample of female twins. Am J Med Genet 96(6):791–796, 2000 11121183
Kalra SK, Swedo SE: Children with obsessive-compulsive disorder: are they just “little adults”?
J Clin Invest 119(4):737–746, 2009 19339765
Pauls DL, Alsobrook JP 2nd, Goodman W, et al: A family study of obsessive-compulsive disorder.
Am J Psychiatry 152(1):76–84, 1995 7802125
Pauls DL, Abramovitch A, Rauch SL, et al: Obsessive-compulsive disorder: an integrative genetic
and neurobiological perspective. Nat Rev Neurosci 15(6):410–424, 2014 24840803
Swedo SE, Leonard HL, Mittleman BB, et al: Identification of children with pediatric autoimmune
neuropsychiatric disorders associated with streptococcal infections by a marker associated
with rheumatic fever. Am J Psychiatry 154(1):110–112, 1997 8988969

202 | Obsessive-Compulsive Disorder—Answer Guide

 C H A P T E R 1 8

Early Onset Schizophrenia

18.1 How does early onset schizophrenia (EOS) compare with adult-onset schizophrenia?

A. EOS is not associated with intellectual deficits.

B. EOS is associated with more genetic mutations, such as copy number variations.
C. Medical conditions are not part of the differential diagnosis for EOS.
D. EOS is not associated with chronic impairment.

The correct response is option B: EOS is associated with more genetic mutations,
such as copy number variations.

Persons with schizophrenia are significantly more likely than unaffected persons
to harbor rare gene-disrupting genomic duplications and deletions, known as
copy number variants (Rapoport et al. 2012; Walsh et al. 2008) (option B is cor-
rect). Individuals with EOS, particularly those with childhood-onset schizophre-
nia (COS), appear to have an even greater risk of harboring one or more
deleterious copy number variants. Approximately 10%–20% of individuals with
EOS have intellectual deficits, ranging from mild to severe (option A is incorrect).
EOS is typically associated with chronic impairment (option D is incorrect). Nu-
merous medical conditions can result in symptoms of psychosis. Recognition and
correction of these conditions can often result in the remission of psychotic symp-
toms and may prevent life-threatening illness (Table 18–1) (option C is incorrect).
(Chapter 18, Early Onset Schizophrenia/Neurodevelopment and Etiology/
Genetic Factors, p. 391; Clinical Presentation, p. 396; Differential Diagnosis:
Other Psychotic Syndromes/Table 18–1, p. 397)

18.2 What neuroanatomical abnormality is most common in early onset and adult-onset
schizophrenia?

A. Increased brain connectivity.

B. Loss of gray matter.
C. White matter enhancement.
D. Increased total brain volumes.

The correct response is option B: Loss of gray matter.

203
TABLE 18–1. Differential diagnosis of early onset schizophrenia

Psychiatric disorder
Psychotic disorder due to another medical condition
Bipolar disorder
Unipolar major depression with psychotic features
Schizoaffective disorder
Posttraumatic stress disorder
Obsessive-compulsive disorder
Autism spectrum disorder
Nonpsychotic emotional and behavioral disorders
Psychosocial factors
Abuse or neglect
Traumatic stress
Secondary gain for symptom reporting
Medical condition
Substance intoxication, overdose
Delirium
Brain neoplasm
Autoimmune encephalitis
Head injury
Seizure disorder
Meningitis
Porphyria
Wilson’s disease
Cerebrovascular accident
AIDS
Electrolyte or fluid abnormalities
Blood glucose abnormalities
Endocrine abnormalities

Multiple neuroanatomical abnormalities have been reported in studies of adults

with schizophrenia, including decreased total brain volumes and loss of gray
matter in the anterior cingulate, frontal and temporal lobes, hippocampus, amyg-
dala, thalamus, and insula (Shepherd et al. 2012). A National Institute of Mental
Health study measured volumetric changes across illness progression in youth
with childhood-onset schizophrenia (COS). Illness was associated with signifi-
cant gray matter volumetric reductions and a more rapid progressive loss of gray
matter over time, revealing a much greater rate of synaptic elimination across ado-
lescence compared with controls (Rapoport et al. 2012) (option B is correct). A key
feature of schizophrenia appears to be brain dysconnectivity—that is, aberrant
connections with and between different brain regions (Fitzsimmons et al. 2013)
(option A is incorrect). Although reductions in brain volumes are subtle and often
vary across studies, alterations tend to be present by the time of first diagnosis,
regardless of age (Ganzola et al. 2014; Rapoport et al. 2012) (option D is incorrect).

204 | Early Onset Schizophrenia—Answer Guide

 White matter impairments have also been implicated in schizophrenia, suggesting
deficits in multiple domains of network connectivity (see Fitzsimmons et al. 2013).
A longitudinal study of COS revealed progression of white matter deficits in a
rostro-caudal pattern, again paralleling the growth trajectory of maturation in
healthy adolescents (Gogtay et al. 2008) (option C is incorrect). (Chapter 18, Early
Onset Schizophrenia/Neurodevelopment and Etiology/Neuroanatomical Ab-
normalities, pp. 392–394)

18.3 What is a common occurrence in both youth and adults with schizophrenia?

A. The differential diagnosis is limited.

B. An individual must have continuous signs of disturbance for at least 1 year for
the diagnosis.
C. Patients progress through four phases: prodromal, acute, recovery, and residual.
D. Neuroanatomical abnormalities are rare.

The correct response is option C: Patients progress through four phases: pro-
dromal, acute, recovery, and residual.

In both youth and adults, schizophrenia is characterized by four phases: prodromal,

acute, recovery, and residual (McClellan et al. 2013) (option C is correct). Patients
typically progress through the last three phases once the illness is established. In-
dividuals are often first assessed during an active acute phase of disease, which
is commonly characterized by significant positive symptoms. During this phase,
patients may be grossly disorganized, confused, and potentially dangerous to
themselves or others. Recovery from the active phase marks a shift to a predomi-
nance of negative symptoms. The time to recovery generally takes 1–6 months or
longer, depending on response to treatment. In youth, recovery is often incomplete.
Schizophrenia has an extensive differential diagnosis, including medical, psychi-
atric, and psychosocial factors (see Table 18–1) (option A is incorrect). To have a
diagnosis of schizophrenia, the individual must have a continuous disturbance
for at least 6 months (option B is incorrect). Neuroanatomical abnormalities, espe-
cially gray matter reductions, are present in both youth and adults with schizo-
phrenia (option D is incorrect). (Chapter 18, Early Onset Schizophrenia/Clinical
Presentation, pp. 394–396; Differential Diagnosis: Other Psychotic Syndromes/
Table 18–1, p. 397)

18.4 Which of the following symptoms of psychosis are most specifically associated
with early onset schizophrenia (EOS)?

A. Negative symptoms.
B. Catatonic symptoms.
C. Complex delusions.
D. Hallucinations and disordered thinking.

The correct response is option A: Negative symptoms.

Early Onset Schizophrenia—Answer Guide | 205

 Psychotic symptoms are the hallmark feature of schizophrenia, characterized by
severe disruption in thought and reality testing, and are generally divided into
two broad clusters. Positive symptoms include hallucinations, delusions, and dis-
organized thought. Negative symptoms include affective flattening, alogia, avoli-
tion, and anhedonia. Among youth with a variety of psychotic illnesses, negative
symptoms appear to be the most specifically associated with EOS (option A is cor-
rect). Hallucinations, disordered thought, and affective flattening are also common
in EOS, whereas complex delusions and catatonia occur less frequently (options
B, C, and D are incorrect). Evaluation of disordered thinking in EOS further de-
mands an appreciation of developmental context and contributing language or
communication deficits but is generally characterized by loose associations and
illogical thinking (Caplan et al. 1989). (Chapter 18, Early Onset Schizophrenia/
Clinical Presentation, p. 394)

18.5 Which of the following is true about early onset schizophrenia (EOS)?

A. Typically, only those children with schizophrenia experience hallucinations.

B. EOS typically occurs around the same time as autism spectrum disorder (ASD).
C. Family, twin, and adoption studies reveal a weak genetic component for
schizophrenia.
D. Longer duration of untreated psychosis and greater severity of negative symp-
toms at the time of diagnosis predict greater functional impairment over time.

The correct response is option D: Longer duration of untreated psychosis and

greater severity of negative symptoms at the time of diagnosis predict greater
functional impairment over time.

Longer duration of untreated psychosis and greater severity of negative symp-

toms at the time of diagnosis predict greater functional impairment over time
(Clarke et al. 2006) (option D is correct). Many children may report symptoms of
hallucinations and delusions, yet most children reporting such symptoms do not
have a true psychotic disorder (option A is incorrect). An earlier age at onset is typical
of ASD compared to schizophrenia (option B is incorrect). Family, twin, and adop-
tion studies reveal a strong genetic component for schizophrenia. The lifetime risk
of developing the illness is 5–20 times higher in first-degree relatives of affected
probands compared with the general population (option C is incorrect). (Chapter
18, Early Onset Schizophrenia/Neurodevelopment and Etiology/Genetic Fac-
tors, p. 390; Clinical Presentation, p. 396; Differentiating True Psychotic Symptoms
From Other Phenomena, pp. 399–400)

References
Caplan R, Guthrie D, Fish B, et al: The Kiddie Formal Thought Disorder Rating Scale: clinical as-
sessment, reliability, and validity. J Am Acad Child Adolesc Psychiatry 28(3):408–416, 1989
2738008
Clarke M, Whitty P, Browne S, et al: Untreated illness and outcome of psychosis. Br J Psychiatry
189:235–240, 2006 16946358

206 | Early Onset Schizophrenia—Answer Guide

Fitzsimmons J, Kubicki M, Shenton ME: Review of functional and anatomical brain connectivity
findings in schizophrenia. Curr Opin Psychiatry 26(2):172–187, 2013 23324948
Ganzola R, Maziade M, Duchesne S: Hippocampus and amygdala volumes in children and young
adults at high-risk of schizophrenia: research synthesis. Schizophr Res 156(1):76–86, 2014
24794883
Gogtay N, Lu A, Leow AD, et al: Three-dimensional brain growth abnormalities in childhood-
onset schizophrenia visualized by using tensor-based morphometry. Proc Natl Acad Sci USA
105(41):15979–15984, 2008 18852461
McClellan J, Stock S, American Academy of Child and Adolescent Psychiatry (AACAP) Commit-
tee on Quality Issues (CQI): Practice parameter for the assessment and treatment of children
and adolescents with schizophrenia. J Am Acad Child Adolesc Psychiatry 52(9):976–990, 2013
23972700
Rapoport JL, Giedd JN, Gogtay N: Neurodevelopmental model of schizophrenia: update 2012.
Mol Psychiatry 17(12):1228-1238, 2012 22488257
Shepherd AM, Laurens KR, Matheson SL, et al: Systematic meta-review and quality assessment of
the structural brain alterations in schizophrenia. Neurosci Biobehav Rev 36(4):1342–1356,
2012 22244985
Walsh T, McClellan JM, McCarthy SE, et al: Rare structural variants disrupt multiple genes in neu-
rodevelopmental pathways in schizophrenia. Science 320(5875):539–543, 2008 18369103

Early Onset Schizophrenia—Answer Guide | 207

 C H A P T E R 1 9

Psychiatric Aspects of
Chronic Physical Disorders
19.1 Which of the following is important for parents helping a child to adjust to his or
her illness?

A. Continuation of “family rules” and appropriate limit setting.

B. Relinquishing control to the child.
C. Giving the child excessive attention and reassurance.
D. Frequently apologizing to the child.

The correct response is option A: Continuation of “family rules” and appropriate

limit setting.

Parental response to illness can have both a beneficial and deleterious effect on
the behavior of the physically ill child (for review, see Shaw and DeMaso 2006).
In addition, family factors play a larger role in the child’s adjustment to illness
than do illness-related factors (Lavigne and Faier-Routman 1993). Both inappro-
priate responses (e.g., threats, punishment, relinquishing control to the child) and
over-responding to the child (via excessive parental attention, reassurance, empa-
thy, and apologies) can interfere with the child’s ability to cope with his or her ill-
ness (Frank et al. 1995; Logan and Scharff 2005) (options B, C, and D are incorrect).
Generally, a calm supportive response, the continuation of familiar “family rules,”
and appropriate limit setting are important for helping the child adjust to his or
her illness (Pederson and Harbaugh 1995) (option A is correct). (Chapter 19, Psy-
chiatric Aspects of Chronic Physical Disorders/Categorical and Noncategorical
Approaches/Impact of Chronic Illness on the Family, p. 416)

19.2 Renal disease affects the metabolism of which of the following medications?

A. Diazepam.
B. Duloxetine.
C. Trazodone.
D. Venlafaxine.

The correct response is option D: Venlafaxine.

209
 Renal disease does not generally affect the metabolism of psychotropic medica-
tions because these drugs are typically fat soluble, easily pass through the blood-
brain barrier, are not dialyzable, and are metabolized by the liver and excreted in
bile. The exceptions are lithium, gabapentin, methylphenidate, venlafaxine, di-
valproex sodium, and topiramate (option D is correct).
Liver disease (not renal disease) affects the ability of medications to bind to
proteins and affects the metabolism of most antidepressants, benzodiazepines
like diazepam (option A is incorrect), and neuroleptics, including haloperidol.
Among antidepressant medications, nefazadone, phenelzine, imipramine, ami-
triptyline, duloxetine, trazodone, and bupropion have the greatest risk for hepato-
toxicity (options B and C are incorrect). (Chapter 19, Psychiatric Aspects of Chronic
Physical Disorders/General Considerations in Psychiatric Management/Medica-
tion Use in Specific Illnesses, p. 418)

19.3 Clonidine can have which of the following cardiac effects?

A. Increase in systolic blood pressure.

B. Decrease in systolic blood pressure.
C. Increase in heart rate.
D. Increase in cardiac output.

The correct response is option B: Decrease in systolic blood pressure.

Clonidine decreases systolic blood pressure (option B is correct; option A is incor-

rect) and decreases cardiac output and heart rate (options C and D are incorrect),
although the medication does not generally cause clinically significant hypoten-
sion when used for psychiatric indications. (Chapter 19, Psychiatric Aspects of
Chronic Physical Disorders/General Considerations in Psychiatric Management/
Medication Use in Specific Illnesses, p. 419)

19.4 Which of the following is an approach-oriented coping style?

A. A coping method that directly handles the stressor and the subsequent emo-
tional response.
B. A coping style that seeks to control upset by evading the stressor.
C. A practical approach that focuses primarily on the problems at hand.
D. A coping style that focuses on regulating emotional responses.

The correct response is option A: A coping method that directly handles the
stressor and the subsequent emotional response.

An individual’s approach to illness is affected by the cognitive, emotional, and be-

havioral responses that characterize coping style. For example, a coping method
that directly handles the stressor and the subsequent emotional response is con-
sidered to be approach-oriented (option A is correct). An avoidance-oriented style
seeks to control upset by evading the stressor (Hubert et al. 1988) (option B is in-

210 | Psychiatric Aspects of Chronic Physical Disorders—Answer Guide

 correct). Some patients and families may also deal with distress by taking a prac-
tical approach and focusing immediately on the problems at hand (option C is
incorrect). Others struggle to maintain emotional control and cope by regulating
their emotional responses (Folkman and Lazarus 1988) (option D is incorrect).
(Chapter 19, Psychiatric Aspects of Chronic Physical Disorders/Psychological
Adjustment/Factors Affecting Adaptation to Illness/Coping Style, pp. 412–413)

19.5 Which of the following is true regarding treatment adherence in physically ill
children?

A. Illnesses that require long periods of follow-up are associated with higher levels
of treatment adherence.
B. Compared with chronic illnesses, acute conditions have higher rates of treat-
ment nonadherence.
C. Family therapy is not indicated for treatment adherence problems.
D. Children are at greater risk for treatment noncompliance when they have a
history of psychological distress.

The correct response is option D: Children are at greater risk for treatment non-
compliance when they have a history of psychological distress.

As many as 33% of patients with acute conditions and 55% of those with chronic
illnesses do not adhere to recommended treatment plans (Sabaté 2003; Shaw et al.
2003) (option B is incorrect), making nonadherence a significant health issue (La
Greca and Bearman 2003; Sabaté 2003). Children are at greater risk for noncom-
pliance when they have a history of psychological distress, including symptoms
of depression, oppositional behavior, and poor impulse control (option D is cor-
rect). Illnesses that require long periods of follow-up with little optimism are as-
sociated with lower levels of adherence (option A is incorrect). Interventions to
improve adherence typically involve increasing parental participation in care and
treatment, educating patient and family on the need for adequate medical super-
vision and follow-up, and initiating indicated behavioral, individual, and family
therapies (Shaw et al. 2003). Spirito and Kazak (2006) recommend specific family
therapy techniques that address nonadherence by normalizing adolescent rebel-
lion, improving family communication, and implementing family problem-
solving strategies (option C is incorrect). (Chapter 19, Psychiatric Aspects of
Chronic Physical Disorders/General Considerations in Psychiatric Management/
Psychosocial Interventions/Adherence, pp. 421–422)

References
Folkman S, Lazarus RS: The relationship between coping and emotion: implications for theory
and research. Soc Sci Med 26(3):309–317, 1988 3279520
Frank NC, Blount RL, Smith AJ, et al: Parent and staff behavior, previous child medical experience,
and maternal anxiety as they relate to child procedural distress and coping. J Pediatr Psychol
20(3):277–289, 1995 7595816

Psychiatric Aspects of Chronic Physical Disorders—Answer Guide | 211

Hubert NC, Jay SM, Saltoun M, et al: Approach-avoidance and distress in children undergoing
preparation for painful medical procedures. J Clin Child Adolesc Psychol 17(3):194–202, 1988
La Greca A, Bearman KJ: Adherence to pediatric treatment regimens, in Handbook of Pediatric
Psychology, 3rd Edition. Edited by Roberts MC. New York, Guilford, 2003, pp 119–140
Lavigne JV, Faier-Routman J: Correlates of psychological adjustment to pediatric physical dis-
orders: a meta-analytic review and comparison with existing models. J Dev Behav Pediatr
14(2):117–123, 1993 8473527
Logan DE, Scharff L: Relationships between family and parent characteristics and functional abil-
ities in children with recurrent pain syndromes: an investigation of moderating effects on the
pathway from pain to disability. J Pediatr Psychol 30(8):698–707, 2005 16093517
Pederson C, Harbaugh BL: Children’s and adolescents’ experiences while undergoing cardiac
catheterization. Matern Child Nurs J 23(1):15–25, 1995 7791378
Sabaté E (ed): Adherence to Long-Term Therapies: Evidence for Action. Geneva, Switzerland, World
Health Organization, 2003
Shaw RJ, DeMaso DR: Clinical Manual of Pediatric Psychosomatic Medicine: Mental Health Con-
sultation With Physically Ill Children and Adolescents. Washington, DC, American Psychiat-
ric Publishing, 2006
Shaw RJ, Palmer L, Blasey C, et al: A typology of non-adherence in pediatric renal transplant re-
cipients. Pediatr Transplant 7(6):489–493, 2003 14870900
Spirito A, Kazak AE: Effective and Emerging Treatments in Pediatric Psychology. Oxford, UK, Ox-
ford University Press, 2006

212 | Psychiatric Aspects of Chronic Physical Disorders—Answer Guide

 C H A P T E R 2 0

Eating and Feeding

Disorders
20.1 Which comorbid psychiatric disorder or class of disorders has the highest lifetime
prevalence in adults with anorexia nervosa according to research data?

A. Substance use disorders.

B. Posttraumatic stress disorder.
C. Anxiety disorders.
D. Mood disorders.

The correct response is option D: Mood disorders.

Several studies of adults suggest that comorbid psychiatric illness is common in

patients with eating disorders. Estimates of the lifetime prevalence of mood dis-
orders range from 50% to 80% (option D is correct), and comorbid anxiety disor-
ders are seen in 30%–65% (option C is incorrect) of individuals with anorexia
nervosa and bulimia nervosa (Herzog et al. 1996; Johnson et al. 2002). While less
is known about comorbidity among adolescents with eating disorders, preliminary
research suggests that similar patterns apply. Data from the National Comorbid-
ity Survey Replication reported a pervasive lifetime psychiatric comorbidity for
adolescents with eating disorders, particularly associated with diagnoses of buli-
mia nervosa and binge-eating disorder. In clinical samples, common comorbidities
include anxiety and depression. Substance use or abuse may also occur (Fischer
and le Grange 2007; Lock et al. 2006). Of note, one study reported higher rates of
substance abuse and posttraumatic stress disorder in women who developed binge-
eating behavior in youth (options A and B are incorrect) (Brewerton et al. 2014).
More longitudinal research is needed to assess the relationship between onset of
child and adolescent eating disorder and psychiatric comorbidity. (Chapter 20,
Eating and Feeding Disorders/Comorbidity/Eating Disorders, p. 441)

213
20.2 The Body Project has focused on which of the following risk factors for eating dis-
order behavior and demonstrated reliable long-term reduction?

A. Teasing by peers.
B. Maternal preoccupation with dietary restriction.
C. Body dissatisfaction.
D. Internalizing the thin-ideal of the fashion industry.

The correct response is option C: Body dissatisfaction.

The Body Project, a manualized dissonance-based prevention program, has shown

reliable long-term reductions in thin-ideal internalization, body dissatisfaction,
and risk for future eating disorder onset (Stice et al. 2008) (option C is correct). Al-
though teasing by peers and maternal preoccupation with dietary restriction are
challenges typical of adolescence that may also contribute to the development of
an eating disorder, these are not risk factors for which the Body Project has demon-
strated long-term reductions (options A and B are incorrect). Although internal-
ization of the thin ideal of the fashion industry may be related to the development
of eating disorders, the Body Project is a prevention program implemented in
high school and college settings rather than an initiative directed at changing me-
dia (option D is incorrect). (Chapter 20, Eating and Feeding Disorders/Etiology
and Risks for Adolescent Eating Disorders, pp. 443–444; Prevention, p. 444)

20.3 Which of the following medical sequelae of anorexia nervosa may persist after
weight restoration?

A. Bradycardia.
B. Osteopenia.
C. Hypothermia.
D. Dehydration.

The correct response is option B: Osteopenia.

For adolescents with anorexia nervosa, the potential for significant growth retar-
dation, pubertal delay or interruption, and peak bone mass reduction is signifi-
cant. Osteopenia and osteoporosis are common—secondary to low weight in
anorexia nervosa—and although bone mineral density improves somewhat with
weight gain, osteopenia often persists (option B is correct). Acutely, bradycardia,
hypothermia, and dehydration may become life threatening (options A, C, and D
are incorrect). (Chapter 20, Eating and Feeding Disorders/Developmental Course
and Outcomes/Eating Disorders, p. 445)

20.4 For which variable did a comparative trial demonstrate that patients in behavior-
al systems family therapy showed greater improvement at the end of treatment
than patients in ego-oriented individual therapy?

A. Eating attitudes.
B. Weight gain.

214 | Eating and Feeding Disorders—Answer Guide

 C. Depression.
D. Self-reported eating-related family conflict.

The correct response is option B: Weight gain.

Patients in behavioral systems family therapy achieved significantly greater weight

gain than those in ego-oriented individual therapy, both at the end of treatment
and at follow-up (Robin et al. 1999) (option B is correct). Both treatments were sim-
ilar in terms of improvement in eating attitudes, depression, and self-reported eat-
ing-related family conflict (options A, C, and D are incorrect). (Chapter 20, Eating
and Feeding Disorders/Treatment for Children and Adolescents With Eating and
Feeding Disorders/Eating Disorders/Psychotherapy/Family-Based Treatment,
p. 450)

20.5 An open-label medication trial including adolescents supports the use of fluoxe-
tine for treatment of which eating or feeding disorder?

A. Pica.
B. Anorexia nervosa.
C. Bulimia nervosa.
D. Rumination.

The correct response is option C: Bulimia nervosa.

One open-label medication trial including adolescents (ages 12–18) with bulimia
nervosa suggested that 8 weeks of fluoxetine (60 mg/day) was well tolerated in
conjunction with supportive psychotherapy and yielded impressive improve-
ment rates of approximately 70% (Kotler et al. 2003) (option C is correct). Several
small randomized controlled trials and case reports have examined newer anti-
psychotic agents in the treatment of adolescents and young adults with anorexia
nervosa (option B is incorrect). No research exists on the treatment of pica (option
A is incorrect). Habit reversal or anxiety management tools may be useful for ru-
mination disorder (option D is incorrect). (Chapter 20, Eating and Feeding Dis-
orders, pp. 454–455)

References
Brewerton TD, Rance SJ, Dansky BS, et al: A comparison of women with child-adolescent versus
adult onset binge eating: results from the National Women’s Study. Int J Eat Disord 47(7):836–
843, 2014 24904009
Fischer S, le Grange D: Comorbidity and high-risk behaviors in treatment-seeking adolescents
with bulimia nervosa. Int J Eat Disord 40(8):751–753, 2007 17683094
Herzog DB, Nussbaum KM, Marmor AK: Comorbidity and outcome in eating disorders. Psychiatr
Clin North Am 19(4):843–859, 1996 9045226
Johnson JG, Cohen P, Kotler L, et al: Psychiatric disorders associated with risk for the development
of eating disorders during adolescence and early adulthood. J Consult Clin Psychol 70(5):
1119–1128, 2002 12362962

Eating and Feeding Disorders—Answer Guide | 215

Kotler LA, Devlin MJ, Davies M, et al: An open trial of fluoxetine for adolescents with bulimia ner-
vosa. J Child Adolesc Psychopharmacol 13(3):329–335, 2003 14642021
Lock J, Couturier J, Agras WS: Comparison of long-term outcomes in adolescents with anorexia
nervosa treated with family therapy. J Am Acad Child Adolesc Psychiatry 45(6):666–672, 2006
16721316
Robin AL, Siegel PT, Moye AW, et al: A controlled comparison of family versus individual therapy
for adolescents with anorexia nervosa. J Am Acad Child Adolesc Psychiatry 38(12):1482–
1489, 1999 10596247
Stice E, Marti CN, Spoor S, et al: Dissonance and healthy weight eating disorder prevention pro-
grams: long-term effects from a randomized efficacy trial. J Consult Clin Psychol 76(2):329–
340, 2008 18377128

216 | Eating and Feeding Disorders—Answer Guide

 C H A P T E R 2 1

Tic Disorders
21.1 What are the most current recommendations regarding the pharmacological
treatment of attention-deficit/hyperactivity disorder (ADHD) in the context of
co-occurring Tourette’s disorder or chronic tics?

A. Longitudinal studies have found that methylphenidate or dextroamphetamine

treatment may cause significant increases in tics.
B. Stimulants are currently the first-line agents for ADHD and comorbid Tourette’s.
C. In one study, worsening of tics in Tourette’s occurred in about one-third of all
patients, and occurred less in patients given placebo than in those given stim-
ulants.
D. Atomoxetine is not recommended in patients with tics because of a lack of
data.

The correct response is option B: Stimulants are currently the first-line agents
for ADHD and comorbid Tourette’s.

Experts have recommended α-adrenergic agonists such as clonidine or guanfacine

as the first-line agents for ADHD symptoms in patients with Tourette’s (Bloch et
al. 2009; McNaught and Mink 2011; Roessner et al. 2011). However, longitudinal
studies found that tics did not increase with methylphenidate or dextroamphetamine
treatment, that any increases are clinically trivial (Roessner et al. 2011; Tourette’s
Syndrome Study Group 2002), and that tics may even decrease with stimulant
treatment (Tourette’s Syndrome Study Group 2002) (option A is incorrect). Thus,
current guidelines now indicate that stimulants are the first-line agents for ADHD
comorbid with Tourette’s (Bloch et al. 2009; Gilbert 2006; Kurlan 2014) (option B
is correct). α-Adrenergic agonists may be effective but carry greater risk of seda-
tion. Methylphenidate and dextroamphetamine appear to be more effective than
clonidine or guanfacine for ADHD symptoms (Scahill et al. 2001; Tourette’s Syn-
drome Study Group 2002). Worsening of tics is seen in about 25% of Tourette’s pa-
tients whether they are given stimulants, clonidine, a combination, or placebo
(Tourette’s Syndrome Study Group 2002) (option C is incorrect). Tics that arise af-
ter starting stimulants may decline over 3 months (Castellanos et al. 1997). Data
also support the use of atomoxetine for patients with tic disorders (Bloch et al.
2009; Pringsheim and Steeves 2011) (option D is incorrect). (Chapter 21, Tic Dis-
orders/Treatment/Treatment of Associated Symptoms, p. 474)
217
21.2 Which of the following is true regarding tics?

A. Tics can mimic others’ movements (echopraxia) or words (echolalia) or sounds

in the environment.
B. The ability to postpone tics is relatively static throughout the day and across
situations.
C. Tics are not typically influenced by suggestion.
D. It is common for tics to follow a physical or emotional stimulus and then stop
soon after the stimulus has ended.

The correct response is option A: Tics can mimic others’ movements (echopraxia)
or words (echolalia) or sounds in the environment.

Tics are best understood as “relatively involuntary.” They may be suppressed suc-
cessfully for minutes to hours, but they cannot be constrained indefinitely. The ca-
pacity to postpone tics varies throughout the day and across situations (option B
is incorrect). One measure of tic severity is how much effort a person must exert
in order to suppress a tic and how successfully he can inhibit tics. Tics may be un-
wittingly influenced by suggestion (option C is incorrect). It is common for some-
one with tics to experience more symptoms while describing them. Tics also can
mimic others’ movements (echopraxia) or words (echolalia) or sounds in the en-
vironment (option A is correct). It is common for a new tic to begin with a stimu-
lus, such as a temporary physical irritation or a forceful emotional experience,
and to continue long after that stimulus has ended (option D is incorrect). (Chap-
ter 21, Tic Disorders/Symptoms and Comorbidity, p. 462)

21.3 Which of the following is true regarding the incidence and course of tic disorders?

A. Tics typically have onset in middle to late adolescence.

B. Most adults who continue to have tics have mild symptoms.
C. The peak incidence of tics is during ages 7–10 years.
D. Less than half of individuals with tics find relief of symptoms in late adolescence
and early adulthood.

The correct response is option B: Most adults who continue to have tics have
mild symptoms.

The typical onset of tic disorders is during childhood and early adolescence (option
A is incorrect). The peak incidence is during ages 4–7 years (option C is incorrect),
and symptoms often are at their worst during late childhood and early adolescence
(Knight et al. 2012). For 85% of individuals, late adolescence and early adulthood
bring relief as tics become quieter (Bloch et al. 2006) (option D is incorrect). Most
adults who continue to have tics have no more than mild symptoms, although
there are exceptions in individuals who continue to have severe tics (option B is
correct). (Chapter 21, Tic Disorders/Symptoms and Comorbidity, p. 463)

218 | Tic Disorders—Answer Guide

21.4 What has been theorized regarding the etiology of tics in various brain regions
and at the cellular level?

A. Norepinephrine and serotonin in medium-size spiny neurons (MSPNs) in the

striatum play a key role in producing tics.
B. Hyperactivation of the basal ganglia and hypoactivation of sensorimotor re-
gions occur in individuals with Tourette’s.
C. Tic movements may result from an imbalance in the relationship between sen-
sorimotor regions and the basal ganglia.
D. When neuronal migration of interneurons acting on MSPNs is impaired during
early childhood, an imbalance occurs in their density and number, leading to
tics.

The correct response is option C: Tic movements may result from an imbalance
in the relationship between sensorimotor regions and the basal ganglia.

At the cellular level in the striatum, MSPNs and dopamine play a key role in pro-
ducing tics (option A is incorrect). MSPNs receive afferents using glutamate (ex-
citatory), γ-aminobutyric acid (GABA; inhibitory), dopamine (D1 excitatory, D2
inhibitory), and serotonin (Leckman et al. 2010) and send inhibitory GABA effer-
ents to the globus pallidus interna. Interneurons acting on these MSPNs, in partic-
ular fast-spiking GABAergic interneurons, and cholinergic tonically active neurons
may play a pivotal role in tic generation (Leckman et al. 2010). There are data sug-
gesting that impaired embryonic neuronal migration of these interneurons leads
to an imbalance in their density and number (Leckman et al. 2010) (option D is in-
correct). Decreased density of these interneurons in critical regions of the basal
ganglia neurotransmitter systems would affect MSPN function. This could lead to
an imbalance in the relationship between sensorimotor regions and the basal gan-
glia, producing movements (Leckman et al. 2010) (option C is correct). It also
would explain the influence of dopamine and serotonin synapses on tic expression
and findings of hypoactivation of the basal ganglia and excessive activation of
sensorimotor regions in those with Tourette’s (McNaught and Mink 2011) (option B
is incorrect). (Chapter 21, Tic Disorders/Neuroanatomy and Neurophysiology,
p. 467)

21.5 Which of the following is false regarding habit reversal training?

A. Tics with premonitory urges are more difficult to treat with habit reversal train-
ing than are tics without these urges.
B. Habit reversal training can be more successful than wait list conditions or sup-
portive therapy.
C. Rhythmic breathing is often used in habit reversal training for vocal tics.
D. The number of children treated with habit reversal training remains small.

The correct response is option A: Tics with premonitory urges are more difficult
to treat with habit reversal training than are tics without these urges.

Tic Disorders—Answer Guide | 219

 In adults, randomized controlled studies suggest that habit reversal training can
be more successful than wait list conditions (McGuire et al. 2014) or active treatment,
such as supportive therapy (Piacentini et al. 2010) (option B is incorrect). Habit re-
versal relies on a competing response procedure—an action that when carried out
makes it impossible to produce the tic, can be sustained for several minutes, and
would not be readily visible to someone who is casually observing the patient. A
premier example would be isometric tensing of muscles in opposition to a tic or
rhythmic breathing to subvert a vocal tic (Piacentini et al. 2010) (option C is incor-
rect). Tics with premonitory urges are perfect candidates for this kind of behav-
ioral maneuver, although the number of children treated with these methods
remains small (option A is correct; option D is incorrect). (Chapter 21, Tic Disor-
ders/Treatment/Specific Interventions/Behavioral Interventions, p. 470)

21.6 According to DSM-5 criteria, which statement is correct in regard to diagnosing

Tourette’s disorder, persistent (chronic) motor or vocal tic disorder, or provisional
tic disorder?

A. For provisional tic disorder to be diagnosed, the tics must have been present
for less than 6 months since first tic onset.
B. For persistent (chronic) motor or vocal tic disorder to be diagnosed, both mul-
tiple motor and one or more vocal tics have been present at some time during
the illness, although not necessarily concurrently.
C. For Tourette’s disorder to be diagnosed, single or multiple motor or vocal tics
have been present during the illness, but not both motor and vocal.
D. For persistent (chronic) motor or vocal tic disorder to be diagnosed, single or
multiple motor or vocal tics have been present during the illness, but not both
motor and vocal.

The correct response is option D: For persistent (chronic) motor or vocal tic dis-
order to be diagnosed, single or multiple motor or vocal tics have been present
during the illness, but not both motor and vocal.

According to the DSM-5 (American Psychiatric Association 2013), for provisional

tic disorder, the tics must have been present for less than 1 year since first tic onset
(Table 21–1) (option A is incorrect). For Tourette’s disorder, both multiple motor
and one or more vocal tics have been present at some time during the illness,
although not necessarily concurrently (option C is incorrect). For persistent
(chronic) motor or vocal tic disorder, single or multiple motor or vocal tics have
been present during the illness, but not both motor and vocal (option B is incor-
rect; option D is correct). (Chapter 21, Tic Disorders/Differential Diagnosis/Box
21–1, p. 464)

220 | Tic Disorders—Answer Guide

TABLE 21–1. DSM-5 Diagnostic Criteria for Tic Disorders
Note: A tic is a sudden, rapid, recurrent, nonrhythmic motor movement or vocalization.
Tourette’s Disorder
A. Both multiple motor and one or more vocal tics have been present at some time during
the illness, although not necessarily concurrently.
B. The tics may wax and wane in frequency but have persisted for more than 1 year since
first tic onset.
C. Onset is before age 18 years.
D. The disturbance is not attributable to the physiological effects of a substance (e.g., co-
caine) or another medical condition (e.g., Huntington’s disease, postviral encephalitis).
Persistent (Chronic) Motor or Vocal Tic Disorder
A. Single or multiple motor or vocal tics have been present during the illness, but not both
motor and vocal.
B. The tics may wax and wane in frequency but have persisted for more than 1 year since
first tic onset.
C. Onset is before age 18 years.
D. The disturbance is not attributable to the physiological effects of a substance (e.g., co-
caine) or another medical condition (e.g., Huntington’s disease, postviral encephalitis).
E. Criteria have never been met for Tourette’s disorder.
Specify if:
With motor tics only
With vocal tics only
Provisional Tic Disorder
A. Single or multiple motor and/or vocal tics.
B. The tics have been present for less than 1 year since first tic onset.
C. Onset is before age 18 years.
D. The disturbance is not attributable to the physiological effects of a substance (e.g., co-
caine) or another medical condition (e.g., Huntington’s disease, postviral encephalitis).
E. Criteria have never been met for Tourette’s disorder or persistent (chronic) motor or vocal
tic disorder.

Source. Reprinted from American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders,
5th Edition. Arlington, VA, American Psychiatric Association, 2013. Copyright © 2013 American Psychiatric
Association. Used with permission.

21.7 How does the prevalence of Tourette’s differ between boys and girls?

A. The prevalence of Tourette’s in boys is four times that of girls.

B. The prevalence of Tourette’s in boys is double that of girls.
C. For chronic motor tics and transient tics, the prevalence in boys is four times
that of girls.
D. For chronic motor tics and transient tics, the prevalence in boys is double that
of girls.

The correct response is option A: The prevalence of Tourette’s in boys is four

times that of girls.

Tic Disorders—Answer Guide | 221

 The prevalence of Tourette’s in boys is four times that of girls (1.06% vs. 0.25%)
(Knight et al. 2012) (option A is correct; option B is incorrect), but for chronic mo-
tor tics and transient tics meta-analysis yields equal prevalence rates for boys and
girls (Knight et al. 2012) (options C and D are incorrect). (Chapter 21, Tic Disor-
ders/Epidemiology, p. 466)

References
American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 5th Edi-
tion. Arlington, VA, American Psychiatric Association, 2013
Bloch MH, Peterson BS, Scahill L, et al: Adulthood outcome of tic and obsessive-compulsive
symptom severity in children with Tourette syndrome. Arch Pediatr Adolesc Med 160(1):65–
69, 2006 16389213
Bloch MH, Panza KE, Landeros-Weisenberger A, et al: Meta-analysis: treatment of attention-
deficit/hyperactivity disorder in children with comorbid tic disorders. J Am Acad Child Ad-
olesc Psychiatry 48(9):884–893, 2009 19625978
Castellanos FX, Giedd JN, Elia J, et al: Controlled stimulant treatment of ADHD and comorbid
Tourette’s syndrome: effects of stimulant and dose. J Am Acad Child Adolesc Psychiatry
36(5):589–596, 1997 9136492
Gilbert D: Treatment of children and adolescents with tics and Tourette syndrome. J Child Neurol
21(8):690–700, 2006 16970870
Knight T, Steeves T, Day L, et al: Prevalence of tic disorders: a systematic review and meta-analysis.
Pediatr Neurol 47(2):77– 90, 2012 22759682
Kurlan RM: Treatment of Tourette syndrome. Neurotherapeutics 11(1):161–165, 2014 24043501
Leckman JF, Bloch MH, Smith ME, et al: Neurobiological substrates of Tourette’s disorder. J Child
Adolesc Psychopharmacol 20(4):237–247, 2010 20807062
McGuire JF, Piacentini J, Brennan EA, et al: A meta-analysis of behavior therapy for Tourette syn-
drome. J Psychiatr Res 50:106–112, 2014 24398255
McNaught KS, Mink JW: Advances in understanding and treatment of Tourette syndrome. Nat
Rev Neurol 7(12):667–676, 2011 22064610
Piacentini J, Woods DW, Scahill L, et al: Behavior therapy for children with Tourette disorder: a
randomized controlled trial. JAMA 303(19):1929–1937, 2010 20483969
Pringsheim T, Steeves T: Pharmacological treatment for attention deficit hyperactivity disorder
(ADHD) in children with comorbid tic disorders. Cochrane Database Syst Rev 4:CD007990,
2011
Roessner V, Plessen KJ, Rothenberger A, et al: European clinical guidelines for Tourette syndrome
and other tic disorders. Part II: pharmacological treatment. Eur Child Adolesc Psychiatry
20(4):173–196, 2011 21445724
Scahill L, Chappell PB, Kim YS, et al: A placebo-controlled study of guanfacine in the treatment
of children with tic disorders and attention deficit hyperactivity disorder. Am J Psychiatry
158(7):1067–1074, 2001 11431228
Tourette’s Syndrome Study Group: Treatment of ADHD in children with tics: a randomized con-
trolled trial. Neurology 58(4):527–536, 2002 11865128

222 | Tic Disorders—Answer Guide

 C H A P T E R 2 2

Elimination Disorders
22.1 Which of the following is true regarding the course and prognosis of enuresis?

A. Enuresis typically persists through adolescence.

B. Enuresis is typically a self-limited disorder with a relatively high rate of spon-
taneous remission.
C. Enuresis requires either pharmacological or behavioral intervention to remit.
D. Enuresis typically remits by age 5.

The correct response is option B: Enuresis is typically a self-limited disorder with

a relatively high rate of spontaneous remission.

Typically, there is a relatively high rate of spontaneous remission of enuresis be-

tween ages 5 and 7 years and after age 12 years (options A and D are incorrect).
Yearly remission rates as high as 14%–16% have been reported (Fritz et al. 2004).
Thus, enuresis is usually a self-limited disorder, and the vast majority of children
who are affected will eventually experience a spontaneous remission (option B is
correct; option C is incorrect). (Chapter 22, Elimination Disorders/Enuresis/
Course and Prognosis, p. 483)

22.2 In a child with enuresis, what is the primary concern with regard to medical co-
morbidity?

A. Sleep apnea.
B. Seizure disorder.
C. Urinary tract infection.
D. Diabetes mellitus.

The correct response is option C: Urinary tract infection.

The primary concern with regard to medical comorbidity for enuresis is the pres-
ence of a urinary tract infection (option C is correct). This is most relevant in fe-
males. The possible presence of structural urinary tract abnormalities has been
extensively investigated. Although some studies report a small percentage of
children for whom this may be a factor, the consensus is that there is not enough

223
 evidence to warrant routinely subjecting children to invasive studies. Other po-
tential causes of enuresis, listed in Table 22–1, include sleep disorders (option A
is incorrect), seizure disorders (option B is incorrect), and diabetes mellitus (op-
tion D is incorrect). The development of all-night polysomnographic studies led
to research that focused on enuresis as a “disorder of arousal,” with the enuretic
events occurring during “deep sleep.” However, subsequent studies with larger
sample sizes indicated that enuretic events occurred during phases of the sleep
cycle in direct proportion to the amount of time spent in that phase. (Chapter 22,
Elimination Disorders/Enuresis/Medical Comorbidity, pp. 480–481; Table 22–1,
p. 481)

22.3 What treatment is recommended for a child with refractory primary enuresis?

A. Imipramine.
B. Psychotherapy.
C. Retention-control training.
D. Reward systems.

The correct response is option A: Imipramine.

The first era of pharmacological treatment followed MacLean’s (1960) observation

that imipramine was an effective treatment, which was subsequently supported
by multiple double-blind studies. The treatment was generally found to be safe,
although there were some tragic reports of fatal overdoses in children. Treatment
guidelines for imipramine suggest cardiac monitoring and periodic blood levels
to guard against toxicity at higher doses. Imipramine is still used for children who
are refractory to other methods of treatment, either as an adjunctive or a stand-
alone treatment (option A is correct). There is no evidence that a traditional psy-
chotherapeutic approach will produce any benefit for primary enuresis, although
it may be helpful in ameliorating the child’s embarrassment and diminished self-
esteem (option B is incorrect). A number of behavioral strategies have been reported,
including retention-control training, evening fluid restriction, reward systems,
and nighttime awakening to urinate. A thorough review of the published literature
regarding these interventions (Glazener and Evans 2004) indicated that the meth-
odology and small sample size of these reports precluded a rigorous meta-analysis
(options C and D are incorrect). (Chapter 22, Elimination Disorders/Enuresis/
Treatment, pp. 484–486)

22.4 The mother of a 6-year-old boy accuses her ex-husband of sexually abusing the
child, who has new-onset voluntary encopresis and hoarding of feces. Which of
the following is an appropriate action for the psychiatrist?

A. Refer the child to a pediatrician to investigate for sexual abuse, because volun-
tary encopresis and hoarding of feces is always diagnostic for sexual abuse.
B. Do not request any medical evaluation because this encopresis is a purely psy-
chological symptom.

224 | Elimination Disorders—Answer Guide

TABLE 22–1. Medical causes of enuresis

Urinary tract infection

Diabetes insipidus
Diabetes mellitus
Urethritis
Seizure disorder
Sickle cell trait
Sleep apnea
Neurogenic bladder
Sleep disorders
Genitourinary malformation or obstruction
Side effect of or idiosyncratic reaction to a medicationa
a
Per case reports regarding selective serotonin reuptake inhibitors, be vigilant for chronological correlations.
Source. Adapted from Dulcan MK, Martini DR, Lake MB: Concise Guide to Child and Adolescent Psychiatry,
3rd Edition. Washington, DC, American Psychiatric Publishing, 2003.

C. Question the mother more carefully because encopresis rarely occurs in boys.
D. Refer the child for a medical evaluation to rule out thyroid disease.

The correct response is option D: Refer the child for a medical evaluation to rule
out thyroid disease.

The first large study (Bellman 1966) found a prevalence of 1.5% for encopresis among
a cohort of 8,863 children ages 7–8 years. The male-to-female ratio was 3:1 (option
C is incorrect). Voluntary encopresis and hoarding of feces may be seen as a sequel
of sexual abuse, but this symptom is not diagnostic of sexual abuse (Mellon et al.
2006) (option A is incorrect). As listed in Table 22–2, potential medical causes of
encopresis include constipation, hypercalcemia, and thyroid disease (option B is
incorrect; option D is correct). (Chapter 22, Elimination Disorders/Encopresis/
Epidemiology, p. 488; Table 22–2, p. 488)

22.5 What is the correct diagnostic terminology for a 7-year-old child who has never
achieved fecal continence and has a history of chronic constipation?

A. Secondary retentive encopresis.

B. Primary retentive encopresis.
C. Secondary nonretentive encopresis.
D. Primary nonretentive encopresis.

The correct response is option B: Primary retentive encopresis.

A distinction is made between primary and secondary encopresis, with the latter term
referring to those who have developed fecal continence and then relapse (options
A and C are incorrect). The categorization of encopresis into two subtypes is clin-
ically quite significant. The category with constipation and overflow incontinence rep-

Elimination Disorders—Answer Guide | 225

TABLE 22–2. Medical causes of encopresis

Constipation
Hirschsprung disease
Medical conditions producing diarrhea
Side effect or idiosyncratic reaction to a medication (maintain vigilance for chronological
correlation)
Painful lesion
Hemorrhoids (contributing to constipation)
Thyroid disease
Hypercalcemia
Lactase deficiency
Pseudo-obstruction
Spina bifida
Cerebral palsy with hypotonia
Rectal stenosis
Anal fissure
Anorectal trauma, including sexual abuse
Source. Adapted from Dulcan MK, Martini DR, Lake MB: Concise Guide to Child and Adolescent Psychiatry,
3rd Edition. Washington, DC, American Psychiatric Publishing, 2003.

resents retentive encopresis, whereas the category without constipation and overflow
incontinence corresponds to nonretentive encopresis (option B is correct; option D is
incorrect). (Chapter 22, Elimination Disorders/Encopresis/Diagnosis, p. 487)

References
Bellman M: Studies on encopresis. Acta Paediatr Scand 56(suppl 170):S1–S151, 1966 5958527
Fritz G, Rockney R, Bernet W, et al: Practice parameter for the assessment and treatment of chil-
dren and adolescents with enuresis. J Am Acad Child Adolesc Psychiatry 43(12):1540–1550,
2004 15564822
Glazener CM, Evans JH: Simple behavioural and physical interventions for nocturnal enuresis in
children. Cochrane Database Syst Rev 2(2):CD003637, 2004 15106210
MacLean RE: Imipramine hydrochloride (Toframil) and enuresis. Am J Psychiatry 117:551, 1960
13764959
Mellon MW, Whiteside SP, Friedrich WN: The relevance of fecal soiling as an indicator of child
sexual abuse: a preliminary analysis. J Dev Behav Pediatr 27(1):25–32, 2006 16511365

226 | Elimination Disorders—Answer Guide

 C H A P T E R 2 3

Sleep Disorders
23.1 What is the first and most important step in assessing children and adolescents for
sleep disorders?

A. A sleep log/sleep diary.

B. A sleep history.
C. Actigraphy.
D. Nocturnal polysomnography.

The correct response is option B: A sleep history.

Taking a sleep history is the first and most important step in assessing children
and adolescents for sleep disorders (option B is correct). Because of a high rate of
sleep comorbidities with other psychiatric disorders, it is essential to obtain a
sleep history in pediatric patients as they present to the clinician’s office with be-
havioral and emotional problems. A sleep log/sleep diary is a valuable tool that
provides nightly information on the child’s bedtime, sleep-onset time, rise time,
and number of nocturnal awakenings. Sleep logs are based on observations and/
or self-perception and lack objective assessment of sleep (option A is incorrect).
Actigraphy uses a small, portable motion sensor that counts and stores move-
ments per minute using a specially designed algorithm. It is a very valuable tool
to assess night-to-night variability of sleep and can detect subtle circadian sleep
disturbances (option C is incorrect). Nocturnal polysomnography is currently the
gold standard procedure for studying sleep-disordered breathing and other types
of intrinsic sleep disorders in children (option D is incorrect). (Chapter 23, Sleep
Disorders/Evaluation, pp. 496–497)

23.2 What is the first line of treatment for childhood insomnia disorders?

A. Nonpharmacological interventions.
B. Sedative-hypnotics.
C. Allowing the child to go to sleep whenever he or she wishes.
D. Other pharmacological agents.

The correct response is option A: Nonpharmacological interventions.

227
 Nonpharmacological interventions are the first choice of treatment for childhood
insomnia disorders (option A is correct). Behavioral interventions include paren-
tal education, sleep hygiene, extinction, graduated extinction, scheduled awaken-
ings, and positive bedtime routines and cognitive-behavioral therapy (Kuhn and
Elliott 2003; Kuhn and Roane 2011; Mindell 1999). Intervention for insomnia in
children should start with establishing appropriate and realistic parent and child
expectations and treatment goals. Age-appropriate sleep duration and bedtime
should be discussed with the parents (option C is incorrect). There are no well-
designed controlled studies of sedative-hypnotics in children (option B is incor-
rect), and there are no pharmacological agents approved by the U.S. Food and
Drug Administration for use in pediatric insomnia (option D is incorrect). It is im-
portant to use sedating pharmacological agents only when behavioral interven-
tions have been tried and found to be ineffective. (Chapter 23, Sleep Disorders/
Evaluation/Insomnia Disorder/Treatment, pp. 500–501)

23.3 What is always required in an accurate DSM-5 diagnosis of narcolepsy?

A. Hypocretin deficiency in the absence of acute brain injury, inflammation, or

infection.
B. Recurrent periods of an irrepressible need to sleep, lapsing into sleep, or napping
recurring within the same day, which must have occurred at least three times
per week over the past 3 months.
C. Nocturnal sleep polysomnography showing rapid eye movement (REM) sleep
latency less than or equal to 15 minutes, or a multiple sleep latency test show-
ing a mean sleep latency less than or equal to 8 minutes and two or more sleep-
onset REM periods.
D. Episodes of cataplexy occurring at least a few times per month.

The correct response is option B: Recurrent periods of an irrepressible need to

sleep, lapsing into sleep, or napping recurring within the same day, which must
have occurred at least three times per week over the past 3 months.

As shown in Table 23–1, in the DSM-5 (American Psychiatric Association 2013) di-
agnostic criteria for narcolepsy, Criterion A requires that the patient have recurrent
periods of an irrepressible need to sleep, lapsing into sleep, or napping occurring
within the same day. These must have been occurring at least three times per
week over the past 3 months (option B is correct). Criterion B in DSM-5 requires
the presence of at least one of the following: 1) episodes of cataplexy occurring at
least a few times per month (option D is incorrect); 2) hypocretin deficiency that
is not in the context of acute brain injury, inflammation, or infection (option A is
incorrect); and 3) nocturnal sleep polysomnography showing rapid eye movement
(REM) sleep latency less than or equal to 15 minutes, or a multiple sleep latency
test showing a mean sleep latency less than or equal to 8 minutes and two or more
sleep-onset REM periods (option C is incorrect). (Chapter 23, Sleep Disorders/
Evaluation/Narcolepsy and Hypersomnolence Disorder/Box 23–2, pp. 504–505)

228 | Sleep Disorders—Answer Guide

TABLE 23–1. DSM-5 Diagnostic Criteria for Narcolepsy

A. Recurrent periods of an irrepressible need to sleep, lapsing into sleep, or napping occur-
ring within the same day. These must have been occurring at least three times per week
over the past 3 months.
B. The presence of at least one of the following:
1. Episodes of cataplexy, defined as either (a) or (b), occurring at least a few times per
month:
a. In individuals with long-standing disease, brief (seconds to minutes) episodes
of sudden bilateral loss of muscle tone with maintained consciousness that are
precipitated by laughter or joking.
b. In children or in individuals within 6 months of onset, spontaneous grimaces or
jaw-opening episodes with tongue thrusting or a global hypotonia, without any
obvious emotional triggers.
2. Hypocretin deficiency, as measured using cerebrospinal fluid (CSF) hypocretin-1 im-
munoreactivity values (less than or equal to one-third of values obtained in healthy
subjects tested using the same assay, or less than or equal to 110 pg/mL). Low CSF
levels of hypocretin-1 must not be observed in the context of acute brain injury, inflam-
mation, or infection.
3. Nocturnal sleep polysomnography showing rapid eye movement (REM) sleep latency
less than or equal to 15 minutes, or a multiple sleep latency test showing a mean sleep
latency less than or equal to 8 minutes and two or more sleep-onset REM periods.

Specify whether:
347.00 (G47.419) Narcolepsy without cataplexy but with hypocretin deficiency:
Criterion B requirements of low CSF hypocretin-1 levels and positive polysomnogra-
phy/multiple sleep latency test are met, but no cataplexy is present (Criterion B1 not
met).
347.01 (G47.411) Narcolepsy with cataplexy but without hypocretin deficiency:
In this rare subtype (less than 5% of narcolepsy cases), Criterion B requirements of
cataplexy and positive polysomnography/multiple sleep latency test are met, but CSF
hypocretin-1 levels are normal (Criterion B2 not met).
347.00 (G47.419) Autosomal dominant cerebellar ataxia, deafness, and narco-
lepsy: This subtype is caused by exon 21 DNA (cytosine-5)-methyltransferase-1 mu-
tations and is characterized by late-onset (age 30–40 years) narcolepsy (with low or
intermediate CSF hypocretin-1 levels), deafness, cerebellar ataxia, and eventually
dementia.
347.00 (G47.419) Autosomal dominant narcolepsy, obesity, and type 2 diabetes:
Narcolepsy, obesity, and type 2 diabetes and low CSF hypocretin-1 levels have been
described in rare cases and are associated with a mutation in the myelin oligodendro-
cyte glycoprotein gene.
347.10 (G47.429) Narcolepsy secondary to another medical condition: This sub-
type is for narcolepsy that develops secondary to medical conditions that cause in-
fectious (e.g., Whipple’s disease, sarcoidosis), traumatic, or tumoral destruction of
hypocretin neurons.
Coding note (for ICD-9-CM code 347.10 only): Code first the underlying medical condi-
tion (e.g., 040.2 Whipple’s disease; 347.10 narcolepsy secondary to Whipple’s disease).

Sleep Disorders—Answer Guide | 229

Specify current severity:
Mild: Infrequent cataplexy (less than once per week), need for naps only once or
twice per day, and less disturbed nocturnal sleep.
Moderate: Cataplexy once daily or every few days, disturbed nocturnal sleep, and
need for multiple naps daily.
Severe: Drug-resistant cataplexy with multiple attacks daily, nearly constant sleepiness,
and disturbed nocturnal sleep (i.e., movements, insomnia, and vivid dreaming).

Source. Reprinted from American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders,
5th Edition. Arlington, VA, American Psychiatric Association, 2013. Copyright © 2013 American Psychiatric
Association. Used with permission.

23.4. How does narcolepsy commonly present in children?

A. Daytime sleepiness, cataplexy, hypnagogic hallucinations, and sleep paralysis.

B. Excessive daytime sleepiness and sleep attacks.
C. Daytime sleepiness, cataplexy, and hypnagogic hallucinations.
D. Excessive daytime sleepiness and sleep attacks, often masked by behavioral
and emotional symptoms such as irritability, hyperactivity, inattention, and
increased sleep needs at younger age.

The correct response is option D: Excessive daytime sleepiness and sleep attacks,
often masked by behavioral and emotional symptoms such as irritability, hy-
peractivity, inattention, and increased sleep needs at a younger age.

Narcolepsy is a rare neurological disorder characterized by daytime sleepiness,

cataplexy (sudden loss of muscle tone triggered by emotional arousal such as
laughter), hypnagogic hallucinations, and sleep paralysis. The classic tetrad of
narcolepsy that includes all of these symptoms is rare in children (option A is in-
correct). Most pediatric patients present with excessive daytime sleepiness and
sleep attacks, often masked by behavioral and emotional symptoms such as irri-
tability, hyperactivity, inattention, and increased sleep needs at younger age (op-
tion D is correct; options B and C are incorrect). (Chapter 23, Sleep Disorders/
Evaluation/Narcolepsy and Hypersomnolence Disorder/Clinical Characteris-
tics, p. 505)

23.5 What is the prevalence of restless legs syndrome in the pediatric population?

A. 0.5%.
B. 1%.
C. 2%.
D. 5%.

The correct response is option C: 2%.

Restless legs syndrome is a common sensorimotor disorder with an estimated

prevalence in the pediatric population of 2% (Picchietti et al. 2007) (option C is

230 | Sleep Disorders—Answer Guide

 correct; options A, B, and D are incorrect). (Chapter 23, Sleep Disorders/Evalua-
tion/Restless Legs Syndrome and Periodic Limb Movement Disorder/Preva-
lence, p. 506)

23.6 What is the treatment of choice for pediatric obstructive sleep apnea (OSA)?

A. Inhaled nasal steroids, antihistamines, and decongestants.

B. Supplemental oxygen.
C. Continuous positive airway pressure (CPAP).
D. Surgery.

The correct response is option D: Surgery.

The treatment of choice for pediatric OSA is surgery, typically adenotonsillec-

tomy (Marcus et al. 2012; Section on Pediatric Pulmonology 2002) (option D is cor-
rect). Polysomnography done after surgery demonstrates that this procedure is
curative in approximately 80% of cases (Lipton and Gozal 2003). Children with al-
lergic rhinitis and/or sinusitis may benefit from inhaled nasal steroids (Brouil-
lette et al. 2001), antihistamines, and decongestants (option A is incorrect). CPAP
is recommended for children who have either failed surgical interventions or are
not surgical candidates (Marcus et al. 1995, 2012; Section on Pediatric Pulmonol-
ogy 2002) (option C is incorrect). The use of CPAP has been approved by the U.S.
Food and Drug Administration for children who are 7 years and older and weigh
more than 40 pounds. Supplemental oxygen is not recommended for routine use
in children with OSA because of the risks of developing hypoventilation (option
B is incorrect). (Chapter 23, Sleep Disorders/Evaluation/Breathing-Related
Sleep Disorders/Treatment, p. 508)

23.7 Which of the following parasomnias might occur during rapid eye movement
(REM) sleep?

A. Night terrors.
B. Confusional arousals.
C. Nightmares.
D. Sleepwalking.

The correct response is option C: Nightmares.

Nightmares and REM behavior sleep disorder occur in REM sleep and usually are
associated with vivid dream recall (option C is correct). Parasomnias such as
sleepwalking, sleeptalking, night terrors, confusional arousals, and nocturnal en-
uresis occur during slow wave sleep (options A, B, and D are incorrect). (Chapter
23, Sleep Disorders/Parasomnias/Clinical Characteristics, pp. 509–510)

Sleep Disorders—Answer Guide | 231

23.8 Which of the following is among the essential parts of treatment for delayed sleep
phase syndrome?

A. Melatonin.
B. Sleep hygiene, family and child education, and the gradual advancement of
sleep phase.
C. Blue light therapy.
D. Bright light therapy.

The correct response is option B: Sleep hygiene, family and child education, and
the gradual advancement of sleep phase.

Sleep hygiene, family and child education, and the gradual advancement of sleep
phase are essential parts of treatment for delayed sleep phase syndrome (option
B is correct). Bright light therapy (5,000–10,000 lux) with morning exposure usu-
ally produces phase advancement in several days (option D is incorrect). Blue
light therapy has demonstrated efficacy in several studies with 20 minutes to an
hour exposure shortly after wake-up time (Revell et al. 2012) (option C is incorrect).
Melatonin administered approximately an hour before bedtime helps to facilitate
sleep phase advancement (option A is incorrect). (Chapter 23, Sleep Disorders/
Circadian Rhythm Sleep-Wake Disorders/Treatment, p. 512)

23.9 What are some of the most prevalent sleep-related symptoms among children and
adolescents with depressive disorders?

A. Problems with sleep initiation, sleep maintenance, and hypersomnia.

B. Snoring.
C. Parasomnias such as sleepwalking, night terrors, confusional arousals, and
rapid eye movement (REM) behavior sleep disorder.
D. Longer sleep-onset latency and less total sleep with reduced sleep efficiency.

The correct response is option A: Problems with sleep initiation, sleep mainte-
nance, and hypersomnia.

Problems with sleep initiation, sleep maintenance, and hypersomnia are some of
the most prevalent symptoms among children and adolescents with depressive
disorders (option A is correct). Snoring and OSA have been implicated in the pos-
sible pathophysiology of attention-deficit/hyperactivity disorder in some children,
an association supported by evidence that adenotonsillectomy for sleep-disordered
breathing can improve attention and hyperactivity (Chervin et al. 2006; Dillon et
al. 2007; Wei et al. 2009) (option B is incorrect). The most frequently reported sleep
problems in autism spectrum disorder are difficulty falling asleep; frequent noc-
turnal and early morning awakenings; irregular sleep-wake cycle; restless sleep;
and parasomnias such as sleepwalking, night terrors, confusional arousals, and
REM behavior sleep disorder (option C is incorrect). Children with generalized
anxiety disorder and obsessive-compulsive disorder demonstrated longer sleep

232 | Sleep Disorders—Answer Guide

 onset latency and less total sleep with reduced sleep efficiency (Alfano and Kim
2011; Alfano et al. 2013) (option D is incorrect). (Chapter 23, Sleep Disorders/
Sleep Problems in Children With Psychiatric Disorders, pp. 513–515)

References
Alfano CA, Kim KL: Objective sleep patterns and severity of symptoms in pediatric obsessive
compulsive disorder: a pilot investigation. J Anxiety Disord 25(6):835–839, 2011 21570250
Alfano CA, Reynolds K, Scott N, et al: Polysomnographic sleep patterns of non-depressed, non-
medicated children with generalized anxiety disorder. J Affect Disord 147(1–3):379–384, 2013
23026127
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obstructive sleep apnea. J Pediatr 138(6):838–844, 2001 11391326
Chervin RD, Ruzicka DL, Giordani BJ, et al: Sleep-disordered breathing, behavior, and cognition
in children before and after adenotonsillectomy. Pediatrics 117(4):e769–e778, 2006 16585288
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before and 1 year after adenotonsillectomy. J Am Acad Child Adolesc Psychiatry 46(11):1425–
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54(6):587–597, 2003 12781314
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ment of childhood obstructive sleep apnea. J Pediatr 127(1):88–94, 1995 7608817
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wakings in young children. J Pediatr Psychol 24(6):465–481, 1999 10608096
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and adolescents—the Peds REST study. Pediatrics 120(2):253–266, 2007 17671050
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can Academy of Pediatrics: Clinical practice guideline: diagnosis and management of child-
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Sleep Disorders—Answer Guide | 233

 C H A P T E R 2 4

Evidence-Based Practice
24.1 Which of the following characterizes the process of evidence-based practice?

A. Decisions about health care are based on conventions of practice.

B. Decisions should be made by those providing care.
C. Decisions should be informed by the tacit and explicit knowledge of those pro-
viding care.
D. Decisions should be made independently of the context of available resources.

The correct response is option C: Decisions should be informed by the tacit and
explicit knowledge of those providing care.

Evidence-based practice is a process in which “decisions about health care are

based on the best available, current, valid and relevant evidence. These decisions
should be made by those receiving care, informed by the tacit and explicit knowl-
edge of those providing care, within the context of available resources” (Dawes et
al. 2005, p. 4) (option C is correct; options A, B, and D are incorrect). (Chapter 24,
Evidence-Based Practice/Defining Evidence-Based Practice[s], pp. 523)

24.2 According to Leape and colleagues (1991), the use of solely supportive treatment
for an abuse victim would be best classified as what type of medical practice error?

A. Performance error.
B. Prevention error.
C. Diagnosis error.
D. Systemic functioning error.

The correct response is option A: Performance error.

Leape and colleagues (1991) classify medical practice “errors” into errors of per-
formance, prevention, diagnosis, drug treatment, and systemic functioning. Un-
der performance, using solely supportive treatment for an abuse victim would be
an error (“use of inappropriate or outmoded form of therapy”) (option A is cor-
rect; options B, C, and D are incorrect), as would maintaining a wait list (“avoid-
able delay in treatment”) in a system with underutilized capacity. Under diagnosis,

235
 use of an instrument with unknown or inadequate reliability or validity if a better
one is available could be considered “use of inappropriate or outmoded diagnos-
tic tests.” Examples in the category of drug treatment would include any errors in
drug choice, dose, or recognizing drug interactions or inadequate monitoring for
side effects (Leape et al. 1991). All these errors would likely result in measurable
functional impairment (e.g., in the first example, the gap between outcome for proven
trauma-specific interventions and that of supportive treatment). (Chapter 24, Evi-
dence-Based Practice/Evidence-Based Practice and the Movement to Reduce
Errors in Medical Practice, p. 524)

24.3 Which of the following is a characteristic of the evidence-based treatment model

and its role in communicating from the body of scientific knowledge to the actors
in the therapeutic change process?

A. The model has emphasized the packing of scientific knowledge into specific
protocols that are disseminated to the field and then tested.
B. The model has emphasized the establishment of social processes to use the ex-
pertise of knowledgeable individuals in plans of care that may be implemented
and monitored.
C. The model emphasizes the integration of evidence at the time of protocol de-
sign and delivers that knowledge to the process of care through the nature and
order of the procedures in the protocol, with controls emphasizing integrity to
the treatment model.
D. The model delivers knowledge to the process of care through individual recall
and social communication with controls that emphasize accountability to at-
tain patient goals.

The correct response is option C: The model emphasizes the integration of ev-
idence at the time of protocol design and delivers that knowledge to the pro-
cess of care through the nature and order of the procedures in the protocol, with
controls emphasizing integrity to the treatment model.

What mechanisms are effective at communicating (e.g., sending messages) from

the body of scientific knowledge to the actors in the therapeutic change process?
To date, the field of child and adolescent psychiatry has offered two dominant
approaches to answering this question. The evidence-based treatment model has em-
phasized the packaging of scientific knowledge into specific protocols that are
tested in the laboratory and disseminated to the field (Rounsaville et al. 2001) (op-
tion A is incorrect); the individualized care model has emphasized the establishment
of social processes (e.g., family treatment teams) to use the expertise of knowledge-
able individuals in plans of care that may be implemented and monitored (Burchard
et al. 2002) (option B is incorrect). These approaches emphasize integration of
knowledge and procedural control at different points in the treatment develop-
ment and delivery process (see Chorpita and Daleiden 2014). The development
and dissemination of specific protocols emphasize integration of evidence at the
time of protocol design and deliver that knowledge to the process of care through

236 | Evidence-Based Practice—Answer Guide

 the nature and order of the procedures in the protocol, with controls emphasizing
integrity to the treatment model (option C is correct). The development of indi-
vidualized treatment plans emphasizes integration of evidence via expert knowl-
edge and delivers that knowledge to the process of care through individual recall
and social communication with controls that emphasize accountability to attain
patient goals (option D is incorrect). Each approach has strengths and highlights
opportunities for integrating knowledge and empirically guiding care. (Chapter 24,
Evidence-Based Practice/Conceptualizing Evidence-Based Practice: A Guiding
Framework, p. 526)

24.4 Which of the following is a factor suggested by studies of implementation to be

critical for success of a health system?

A. Avoidance of risk taking.

B. Unavailability of “extra” resources.
C. Accessible staff training and coaching.
D. A culture that encourages proprietorship of knowledge.

The correct response is option C: Accessible staff training and coaching.

Studies of implementation suggest that several factors are critical for success:
strong leadership with a clear strategy, visionary staff in key positions, openness
to experimentation and risk taking (option A is incorrect), available “extra” re-
sources (option B is incorrect), accessible staff training and coaching (option C is
correct), a culture that includes knowledge sharing (option D is incorrect), and ef-
fective monitoring and feedback systems (Fixsen et al. 2005; Greenhalgh et al.
2004). Building these features into the context of care may help support effective
transfer of knowledge into clinical operations of health systems. (Chapter 24,
Evidence-Based Practice/Implementation Within a Specific Context, p. 527)

24.5 Which of the following reflects attitudes regarding structured approaches to in-
terviewing and diagnosis?

A. Patients tend to prefer unstructured approaches.

B. Patients perceive structured and unstructured approaches to be equally com-
prehensive.
C. Patients perceive structured approaches as damaging of rapport.
D. Clinicians’ beliefs of patients’ perceptions regarding structured approaches
generally do not reflect patients’ actual perceptions.

The correct response is option D: Clinicians’ beliefs of patients’ perceptions

generally do not reflect patients’ actual perceptions.

Clinicians too often rely on informal, unstructured interviews and typically agree
on formulations at levels only slightly better than chance. Contrary to clinicians’
beliefs, patients actually tend to prefer structured approaches to interviewing and
diagnoses, perceiving these as more comprehensive and as building rapport

Evidence-Based Practice—Answer Guide | 237

 rather than damaging it (Bruchmüller et al. 2011; Suppiger et al. 2009) (option D
is correct; options A, B, and C are incorrect). (Chapter 24, Evidence-Based Prac-
tice/Assessment, p. 528)

24.6 Which of the following is a common error that occurs in the evaluation process,
in treatment planning, and in tracking outcomes?

A. Overinclusion of comorbid disorders in the course of evaluation.

B. Reluctance to assign “no disorder” in the course of evaluation.
C. Failure to dismiss existing evidence as irrelevant or infeasible.
D. Overreliance on a validated instrument to track a targeted domain.

The correct response is option B: Reluctance to assign “no disorder” in the course
of an evaluation.

Common errors of omission occur in the evaluation process, in treatment plan-

ning (insufficient use of existing evidence), and when outcome tracking is absent.
Evaluating clinicians commonly omit comorbid disorders (option A is incorrect)
and are reluctant to assign “no disorder” (option B is correct). Agreement be-
tween diagnoses made by clinicians and structured interviews is poor (Jensen
and Weisz 2002; Rettew et al. 2009). As in other specialties, clinicians often do not
search existing evidence or dismiss it as irrelevant or infeasible (Hamilton et al.
2011) (option C is incorrect). Finally, many youth are treated without ongoing
tracking of a targeted domain using a validated instrument (option D is incorrect).
(Chapter 24, Evidence-Based Practice/Treatment Planning and Selection/Pharma-
cological Treatment, p. 531)

References
Bruchmüller K, Margraf J, Suppiger A, et al: Popular or unpopular? Therapists’ use of structured
interviews and their estimation of patient acceptance. Behav Ther 42(4):634–643, 2011
22035992
Burchard JD, Bruns EJ, Burchard SN: The wraparound approach, in Community Treatment for
Youth: Evidence-Based Interventions for Severe Emotional and Behavioral Disorders. Edited
by Burns BJ, Hoagwood K. New York, Oxford University Press, 2002, pp 69–90
Chorpita BF, Daleiden EL: Structuring the collaboration of science and service in pursuit of a
shared vision. J Clin Child Adolesc Psychol 43(2):323–338, 2014 23981145
Dawes M, Summerskill W, Glasziou P, et al: Sicily statement on evidence-based practice. BMC
Med Educ 5(1), 2005 15634359
Fixsen D, Naoom S, Blase K, et al: Implementation Research: A Synthesis of the Literature. Tampa,
University of South Florida, 2005. Available at: http://nirn.fpg.unc.edu/sites/
nirn.fpg.unc.edu/files/resources/NIRN-MonographFull-01-2005.pdf. Accessed January 2,
2006.
Greenhalgh T, Robert G, Bate P, et al: How to Spread Good Ideas. Southampton, UK, National Co-
ordinating Centre for NHS Service Delivery and Organisation R & D, 2004. Available at:
http://www.cs.kent.ac.uk/people/staff/saf/share/great-missenden/referencepapers/
Overviews/NHS-lit-review.pdf. Accessed March 30, 2015.

238 | Evidence-Based Practice—Answer Guide

Hamilton J, Daleiden E, Dopson S: Implementing evidence-based practices for youth in an HMO:
the roles of external ratings and market share. Adm Policy Ment Health 38(3):203–210, 2011
21461777
Jensen AL, Weisz JR: Assessing match and mismatch between practitioner-generated and stan-
dardized interview-generated diagnoses for clinic-referred children and adolescents. J Con-
sult Clin Psychol 70(1):158–168, 2002 11860042
Leape LL, Brennan TA, Laird N, et al: The nature of adverse events in hospitalized patients. Re-
sults of the Harvard Medical Practice Study II. N Engl J Med 324(6):377–384, 1991 1824793
Rettew DC, Lynch AD, Achenbach TM, et al: Meta-analyses of agreement between diagnoses
made from clinical evaluations and standardized diagnostic interviews. Int J Methods Psychi-
atr Res 18(3):169–184, 2009 19701924
Rounsaville BJ, Carroll KM, Onken LS: A stage model of behavioral therapies research: getting
started and moving on from stage 1. Clin Psychol Sci Pract 8(2):133–142, 2001
Suppiger A, In-Albon T, Hendriksen S, et al: Acceptance of structured diagnostic interviews for
mental disorders in clinical practice and research settings. Behav Ther 40(3):272–279, 2009
19647528

Evidence-Based Practice—Answer Guide | 239

 C H A P T E R 2 5

Child Abuse and Neglect

25.1 Treatment of an abused child should focus on which of the following goals?

A. Protecting the child.

B. Reducing familial cohesion.
C. Telling the child the abuse is his or her fault.
D. Avoiding issues of betrayal.

The correct response is option A: Protecting the child.

The major goals of treatment are first to protect the child and strengthen the fam-
ily and then to address the impact of past abuse in treatment of the child and the
family (option A is correct). Psychotherapy of the child should include creating a
therapeutic environment, in either individual or group settings, that allows the
child to master the trauma, in part through controlled repetitions of the event us-
ing symbolic reenactments with dolls, puppets, drawings, or other expressive
media. Familial cohesion, including competent foster care, has been related to de-
veloping resilience in children (Heller et al. 1999). A degree of stability within the
family plays an important role. In general, parent support and involvement in
treatment with the affected child yield a significantly better outcome (option B is
incorrect). The child must be told that the abuse is not his or her fault and that he
or she is not to blame (option C is incorrect). Terr (1996) reminds clinicians of the
need to explore issues of betrayal, overexcitement, and personal responsibility, es-
pecially in children who have been abused within their own families (option D is
incorrect). (Chapter 25, Child Abuse and Neglect/Child and Parent Treatment,
pp. 550–553)

25.2 What kind of sexual activity generally involves mutually interested children at
similar ages and developmental stages and does not involve coercion?

A. Sexual abuse.
B. Sexual play.
C. Sexual contact that also involves an adult.
D. Sexual contact that also involves a parent.

241
 The correct response is option B: Sexual play.

Sexual play generally involves mutually interested children at similar ages and de-
velopmental stages and does not involve coercion (American Academy of Pediat-
rics Committee on Child Abuse and Neglect 1999) (option B is correct). Legal
definitions of sexual abuse generally involve sexual contact between an adult and
a minor child (Green 1997) (option C is incorrect). If both the perpetrator and the
victim are minors, abuse can be understood to have occurred if there is a signifi-
cant discrepancy in age or there is coercion (option A is incorrect). Incest refers to
the sexual abuse of children within the context of the nuclear family, generally in-
volving sexual activity between a parent and child or among siblings (option D is
incorrect). (Chapter 25, Child Abuse and Neglect/Definitions, pp. 539–540)

25.3 Which of the following is indicative of whiplash shaken baby syndrome?

A. Repeated urinary tract infections and/or hematuria.

B. Retinal hemorrhages.
C. Vague somatic complaints such as abdominal pain and headaches.
D. External cranial trauma.

The correct response is option B: Retinal hemorrhages.

In 1972, pediatric radiologist John Caffey coined the term whiplash shaken baby syn-
drome to describe a constellation of clinical findings in infants and toddlers, in-
cluding retinal hemorrhages, subdural or subarachnoid hemorrhages, and little
or no evidence of external cranial trauma (option B is correct; option D is incor-
rect). It was postulated that whiplash forces caused subdural hematomas by tear-
ing cortical bridging veins. Repeated urinary tract infections and/or hematuria
and vague somatic complaints such as abdominal pain and headaches may be
medical findings of sexual abuse (Table 25–1) (options A and C are incorrect).
(Chapter 25, Child Abuse and Neglect/Clinical Presentation, p. 542; Table 25–3,
p. 543)

TABLE 25–1. Medical findings of sexual abuse

Vague somatic complaints such as abdominal pain and headaches
Secondary enuresis and/or encopresis
Redness or irritation of the vulva; anogenital injuries such as lacerations, scarring, or bruising
of genitalia; anal dilatation or scarring
Repeated urinary tract infections and/or hematuria
Anal fissures or blood in the stool

25.4 Which of the following neuroanatomical findings is most associated with posttrau-
matic stress disorder?

A. Increased hippocampal size.

B. Normal limbic activity.

242 | Child Abuse and Neglect—Answer Guide

 C. Decreased hippocampal size.
D. No change in hippocampal size.

The correct response is option C: Decreased hippocampal size.

Adults with posttraumatic stress disorder due to severe sexual or physical abuse
have decreased hippocampal size, detected with magnetic resonance imaging
and positron emission tomographic scans (Bremner et al. 2003) (option C is cor-
rect; options A and D are incorrect). Studies of abused children have revealed hip-
pocampal and limbic abnormalities, which may predispose these children to
memory deficits and emotional dysregulation (option B is incorrect). (Chapter 25,
Child Abuse and Neglect/Diagnostic Considerations and Comorbidity/Impact
of Abuse, p. 546)

25.5 What is the first step in the treatment of children who are victims of abuse?

A. Educate parents about appropriate forms of child discipline.

B. Make certain that the child is protected and safe from further injury and abuse.
C. Promote social awareness through media campaigns and public education.
D. Identify whether the child belongs to a high-risk group.

The correct response is option B: Make certain that the child is protected and
safe from further injury and abuse.

The cornerstone of treatment of children who are victims of abuse is first to make
certain that the child is protected and safe from further injury and abuse (option
B is correct). Making a report to child protective services needs to occur as soon
as possible, preferably in the context of the initial evaluation or first disclosure.
Additional prevention strategies include 1) competency enhancement with par-
ent education programs (option A is incorrect); 2) media campaigns, hotlines, and
parent socialization programs (option C is incorrect); and 3) targeting of high-risk
groups, such as single parents and teenage parents, parents of low socioeconomic
status, and parents with neurocognitively compromised children (option D is in-
correct). (Chapter 25, Child Abuse and Neglect/Prevention, p. 550)

References
American Academy of Pediatrics Committee on Child Abuse and Neglect: Guidelines for the eval-
uation of sexual abuse of children: subject review. Pediatrics 103(1):186–191, 1999 9917463
Bremner JD, Vythilingam M, Vermetten E, et al: MRI and PET study of deficits in hippocampal
structure and function in women with childhood sexual abuse and posttraumatic stress dis-
order. Am J Psychiatry 160(5):924–932, 2003 12727697
Green AH: Physical abuse of children, in Textbook of Child and Adolescent Psychiatry, 2nd Edi-
tion. Edited by Weiner JM. Washington, DC, American Psychiatric Press, 1997, pp 687–697
Heller SS, Larrieu JA, D’Imperio R, et al: Research on resilience to child maltreatment: empirical
considerations. Child Abuse Negl 23(4):321–338, 1999 10321770
Terr LC: Acute responses to external events and posttraumatic stress disorder, in Child and Ado-
lescent Psychiatry: A Comprehensive Textbook, 2nd Edition. Edited by Lewis M. Baltimore,
MD, Williams & Wilkins, 1996

Child Abuse and Neglect—Answer Guide | 243

 C H A P T E R 2 6

Cultural and Religious Issues

26.1 Which of the following statements defines cultural psychiatry?

A. The discipline concerned with an individual’s identity with a group of people

sharing common origins, history, customs, and beliefs as it affects description,
assessment, diagnosis, biopsychosocial formulation, treatment planning, and
training in all aspects of psychiatric practice.
B. The discipline concerned with matters of culture, ethnicity, and race as they af-
fect description, assessment, diagnosis, biopsychosocial formulation, treat-
ment planning, and training in all aspects of psychiatric practice.
C. The discipline concerned with physical, biological, and genetic qualities of
humans, as they affect description, assessment, diagnosis, biopsychosocial
formulation, treatment planning, and training in all aspects of psychiatric
practice.
D. The discipline concerned with the set of values, behavioral norms, and mean-
ing used by members of a particular society to construct their unique view of
the world as they affect description, assessment, diagnosis, biopsychosocial
formulation, treatment planning, and training in all aspects of psychiatric
practice.

The correct response is option B: The discipline concerned with matters of cul-
ture, ethnicity, and race as they affect description, assessment, diagnosis, bio-
psychosocial formulation, treatment planning, and training in all aspects of
psychiatric practice.

Cultural psychiatry is the discipline concerned with matters of culture, ethnicity,

and race as they affect description, assessment, diagnosis, biopsychosocial formu-
lation, treatment planning, and training in all aspects of psychiatric practice (op-
tion B is correct). Culture is dynamic, and it shapes and is shaped by individuals
and evolves over time as it is passed on to succeeding generations. It shapes
meanings and expressions of disease, illness, pain, and suffering, which in turn
influence a people’s receptivity to medical and psychiatric care. The Group for the
Advancement of Psychiatry (2002) defines culture as “a set of meaning, behavioral
norms, and values used by members of a particular society as they construct their
unique view of the world. These...include social relationships, language, nonver-

245
 bal expression of thoughts and emotions, religious beliefs, moral thought, tech-
nology, and financial philosophy” (option D is incorrect). Ethnicity encompasses
one’s identity with a group of people sharing common origins, history, customs,
and beliefs. Ethnicity may include geographical, national, and religious identities,
such as Irish Catholic, Vietnamese American, or Greek Orthodox (option A is in-
correct). Race refers to physical, biological, and genetic qualities of humans, partic-
ularly as these features lead to categorization of visible similarities or differences
(option C is incorrect). (Chapter 26, Cultural and Religious Issues/History of
Cultural Psychiatry and Key Definitions, p. 560)

26.2 What are cultural syndromes?

A. A way of conceptualizing and communicating about suffering experienced by

individuals within a cultural group.
B. A set of consistent and specific symptoms occurring in cultural groups or con-
texts.
C. The reason or reasons for symptoms or distress within a cultural group.
D. The cultural features of the relationship between the individual and the clinician.

The correct response is option B: A set of consistent and specific symptoms oc-
curring in cultural groups or contexts.

In DSM-5 (American Psychiatric Association 2013), the term culture-bound syn-

drome has been retired in favor of three more clinically useful constructs. Cultural
syndromes are consistent and specific symptoms occurring in cultural groups or
contexts (option B is correct). Cultural idiom of distress refers to a way of conceptu-
alizing and communicating about suffering experienced by individuals within a
cultural group (option A is incorrect). Cultural explanation or perceived cause provides
a reason or reasons for symptoms or distress (option C is incorrect). These are
helpful in devising a cultural formulation. DSM-5 offers an updated formulation
outline, requiring consideration of 1) cultural identity of the individual, 2) cultural
conceptualizations of distress, 3) psychosocial stressors and cultural features of
vulnerability and resilience, 4) cultural features of the relationship between the in-
dividual and the clinician (option D is incorrect), and 5) overall cultural assessment.
(Chapter 26, Cultural and Religious Issues/Culture Competence and DSM-5,
p. 562)

26.3 Which are the foundational units in which children are conceived, grow, and de-
velop in virtually every culture?

A. Marriage and family.

B. Family and ethnicity.
C. Marriage and race.
D. Family and religion.

The correct response is option A: Marriage and family.

246 | Cultural and Religious Issues—Answer Guide

 In virtually all cultures, marriage and family are the foundational units in which
children are conceived, grow, and develop (option A is correct). Marriage is the so-
cially sanctioned unit, usually intended to be long lasting, if not permanent, from
which a family is created and nurtured. Families, in turn, function as groups
through which individuals grow physically, emotionally, and socially; learn to re-
late to the outside world; and transmit cultural beliefs, histories, and behaviors to
the next generation. Ethnicity encompasses one’s identity with a group of people
sharing common origins, history, customs, and beliefs. Ethnicity may include geo-
graphical, national, and religious identities, such as Irish Catholic, Vietnamese
American, or Greek Orthodox (option B is incorrect). Race refers to physical, bio-
logical, and genetic qualities of humans, particularly as these features lead to cat-
egorization of visible similarities or differences (option C is incorrect). Religion is
an organized system of beliefs, principles, rituals, practices, and related symbols
that brings individuals and groups to sacred or ultimate reality and truth. It in-
cludes relationships with others, whether inside a community of individuals with
shared beliefs or external to a like-minded community (option D is incorrect).
(Chapter 26, Cultural and Religious Issues, pp. 560–563)

26.4 Which of the following is a characteristic of culturally competent child and ado-
lescent mental health clinicians?

A. Disregard the cultural biases they bring to their work.

B. Appreciate cultural influences on development, distress, and symptom ex-
pression.
C. Exclude cultural strengths in assessment and treatment.
D. Do not ask about individual and group trauma associated with immigration.

The correct response is option B: Appreciate cultural influences on develop-

ment, distress, and symptom expression.

As listed in Table 26–1, culturally competent child and adolescent mental health
clinicians appreciate cultural influences on development, distress, and symptom
expression (option B is correct). Additional characteristics of these clinicians in-
clude being insightful regarding the cultural biases they bring to their work (op-
tion A is incorrect), including cultural strengths in assessment and treatment
(option C is incorrect), and asking about individual and group trauma associated
with immigration (option D is incorrect). (Chapter 26, Cultural and Religious Is-
sues/ Culture Competence and DSM-5/Table 26–1, p. 563)

26.5 Which of the following best describes some of the concepts of fundamentalism?

A. Religion and faith communities that are not restricted to organized religion
and group membership.
B. Organized system of beliefs, principles, rituals, practices, and related symbols
that brings individuals and groups to sacred or ultimate reality and truth.

Cultural and Religious Issues—Answer Guide | 247

TABLE 26–1. Culturally competent child and adolescent mental health
clinicians
Recognize and address obstacles to mental health services for culturally diverse populations
Provide care in patients’ preferred language when possible
Appreciate the implications of dual or multiple languages for a child’s acculturation and
development
Are insightful regarding the cultural biases they bring to their work
Appreciate cultural influences on development, distress, and symptom expression
Ask about individual and group trauma associated with immigration
Address different degrees of acculturation and associated stress in multigenerational families
Include extended family members and important others in assessment and treatment
Include cultural strengths in assessment and treatment
Work with culturally diverse families in familiar community settings when possible
Use evidence-based practices in ethnic/cultural psychopharmacology, behavioral
management, and psychosocial treatments
Source. Adapted from Pumariega et al. 2013.

C. Philosophy of life or belief system that addresses life’s most common, basic
questions.
D. Strict interpretation of sacred writings, traditional lifestyle practices guided by
religious teachings, and suspicion of or resistance to modernity.

The correct response is option D: Strict interpretation of sacred writings, tradi-

tional lifestyle practices guided by religious teachings, and suspicion of or re-
sistance to modernity.

Religion is an organized system of beliefs, principles, rituals, practices, and related

symbols that brings individuals and groups to sacred or ultimate reality and
truth. It includes relationships with others, whether inside a community of indi-
viduals with shared beliefs or external to a like-minded community (option B is
incorrect). Spirituality includes religion and faith communities but is not restricted
to organized religion and group membership. It may encompass an individual’s
understandings of and quest for ultimate meaning in life’s deepest, most perplex-
ing questions and mysteries (Koenig et al. 2001) (option A is incorrect). Worldview
refers to a philosophy of life or belief system that addresses life’s most common,
basic questions. These include the meaning and purpose of life, life direction and
goals, what is good and desirable in life, happiness, relationships with others, suf-
fering, and death (option C is incorrect). In the United States, the term fundamen-
talism primarily is applied to very conservative Protestantism. However, the concept
of fundamentalism, including strict interpretation of sacred writings, traditional
lifestyle practices guided by religious teachings, and suspicion of or resistance to
modernity, may be found worldwide in Judaism, Islam, Hinduism, and other ma-
jor world faith traditions (Ammerman 1991; Hood et al. 2005; Wentz 2003) (option
D is correct). (Chapter 26, Cultural and Religious Issues/ Religion, Spirituality,
and Culture/Basic Definitions and Relevance to Care, pp. 562–564)

248 | Cultural and Religious Issues—Answer Guide

References
American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 5th Edi-
tion. Arlington, VA, American Psychiatric Association, 2013
Ammerman NT: North American Protestant fundamentalism, in Fundamentalisms Observed. Ed-
ited by Marty ME, Appleby RS. Chicago, IL, University of Chicago Press, 1991, pp 1–65
Group for the Advancement of Psychiatry: Committee on Cultural Psychiatry: Cultural Assess-
ment in Clinical Psychiatry. Washington, DC, American Psychiatric Publishing, 2002
Hood RW Jr, Hill PC, Williamson WP: The Psychology of Religious Fundamentalism. New York,
Guilford, 2005
Koenig HG, McCullough ME, Larson DB: Handbook of Religion and Health. New York, Oxford
University Press, 2001
Pumariega AJ, Rothe E, Mian A, et al: Practice parameter for cultural competence in child and ad-
olescent psychiatric practice. J Am Acad Child Adolesc Psychiatry 52(10):1101–1115, 2013
24074479
Wentz RE: American Religious Traditions: The Shaping of Religion in the United States. Minneap-
olis, MN, Fortress Press, 2003

Cultural and Religious Issues—Answer Guide | 249

 C H A P T E R 2 7

Youth Suicide
27.1 A 17-year-old girl has a 3-year history of major depressive disorder and intermit-
tent suicidal thoughts. She discloses that she has new intermittent thoughts of
cutting, and made one very superficial cut with her razor a week ago, following
a fight she had with her boyfriend. She denies current acute suicidal ideation.
What is the most important next step in your clinical management?

A. Ask her to sign a safety contract for times she has suicidal urges.
B. Discuss starting medication to reduce suicide risk.
C. Take her to the emergency room for possible inpatient hospitalization.
D. Discuss a plan for safety with her and her parents, including how to ensure her
safety.

The correct response is option D: Discuss a plan for safety with her and her par-
ents, including how to ensure her safety.

Safety planning is considered best practice for suicide prevention with at-risk in-
dividuals (Suicide Prevention Resource Center 2012). The creation of a safety plan
involves working with the patient and family to collaboratively create a list of
strategies that the patient agrees to use when a suicidal crisis occurs (option D is
correct) (Brent et al. 2011; Stanley et al. 2009). A review found that no-harm con-
tracts alone are not a sufficient method for suicide prevention (Lewis 2007) (op-
tion A is incorrect). Data from psychosocial and pharmacological studies suggest
that the treatment of depression may not be sufficient to reduce suicidal risk;
rather, specific treatments targeting suicidality may be required (Emslie et al. 2006).
Although no pharmacological treatment has demonstrated efficacy in treating
suicidality per se in youth, medications that target aggression and emotional dys-
regulation such as lithium and atypical (second-generation) antipsychotics may
hold promise (option B is incorrect). Although psychiatric hospital admission is be-
lieved to provide a safe environment for suicidal patients to resolve acute suicidal
crises, there is no research to support the efficacy of inpatient hospitalization in
reducing suicidality (option C is incorrect). (Chapter 27, Youth Suicide/Treatment,
pp. 576–577)

251
27.2 What is the most accurate statement regarding psychopathology in youth who die
by suicide?

A. A significant proportion of youth suicide attempters have no clear evidence of

psychopathology.
B. Persistent negative affect (neuroticism) is one of the strongest risk factors.
C. A strong desire for perfectionism is closely associated with completed suicides.
D. Family history of bipolar and major depressive disorders, even without a his-
tory of completed suicides, places youth at higher risk for completed suicide.

The correct response is option B: Persistent negative affect (neuroticism) is one

of the strongest risk factors.

In terms of personality traits, neuroticism—the tendency to experience prolonged

and severe negative affect in response to stress—has repeatedly been associated
with suicide attempts in youth, above and beyond its association with other risk
factors (Roy 2002) (option B is correct). The overwhelming majority (close to 90%)
of youth who die by suicide have evidence of serious psychopathology (Brent et
al. 1988). Youth who attempt suicide also demonstrate high rates of psychopathol-
ogy, with estimates as high as 96% (Nock et al. 2013) (option A is incorrect). Al-
though perfectionism is another personality trait associated with suicide attempts
in youth, studies have failed to find a link between perfectionism and completed
suicide (Shaffer et al. 1996) (option C is incorrect). Research suggests both envi-
ronmental and genetic mechanisms for the familial transmission of suicidal be-
havior, and evidence suggests that suicidal behavior is transmitted in families
distinct from its association with familial psychiatric illness. The first-degree rel-
atives of adolescent suicide attempters and completers exhibit a suicide attempt
rate two to six times higher than that found in the general population, even after
controlling for higher rates of psychopathology (Brent and Melhem 2008) (option
D is incorrect). (Chapter 27, Youth Suicide/Risk Factors, pp. 573–574)

27.3 What would be the most helpful short- and long-term psychopharmacological
and psychotherapeutic approach to treatment that would decrease suicidal ide-
ation according to the research?

A. A combined approach, utilizing both a selective serotonin reuptake inhibitor

(SSRI) and cognitive-behavioral therapy (CBT).
B. A combined approach, utilizing SSRI, CBT, and family psychoeducation.
C. An approach utilizing multisystemic therapy, a family-based treatment.
D. Consideration of family therapy and either CBT or dialectical behavior therapy,
and cautious use of SSRIs, due to increased risk of suicidal ideation.

The correct response is option A: A combined approach, utilizing both a selective

serotonin reuptake inhibitor (SSRI) and cognitive-behavioral therapy (CBT).

In the multisite Treatment for Adolescents with Depression Study, in which flu-
oxetine, CBT, and the combination were compared with each other and with pla-

252 | Youth Suicide—Answer Guide

 cebo, both fluoxetine and the combination produced substantial improvements in
depression relative to placebo and CBT alone, but only the combination was as-
sociated with decreased suicidal ideation compared with placebo (March et al.
2004) (option A is correct). In addition, Rotheram-Borus et al. (2000) compared
brief family CBT alone with an “enhanced” CBT condition in which an additional
family psychoeducation session was delivered in the emergency room for female
adolescent suicide attempters. The enhanced CBT group showed increased ad-
herence to CBT treatment and lower suicidal ideation at posttreatment. At 18-
month follow-up, the rates of attempts and suicidal ideation were not different
between the two groups (option B is incorrect). Huey et al. (2004) compared mul-
tisystemic therapy—an intensive family-based treatment delivered in the pa-
tient’s natural environment that involves case management and both individual
and family treatment—with psychiatric hospitalization and usual care for youth
presenting to the emergency room with suicidal ideation, suicide attempt, homi-
cidal ideation, or psychosis. Rates of reattempt were significantly lower in the
multisystemic therapy group than in the usual-care group at 1-year follow-up.
There were no group differences for suicidal ideation, depression, or hopeless-
ness (option C is incorrect). The decrease in SSRI prescriptions following the pub-
lic health warning of a possible association between SSRIs and suicide in youth
was associated with a marked increase in youth suicide in the United States (Gib-
bons et al. 2007). Furthermore, one meta-analysis supports the assertion that 11
times more depressed youth will show a good clinical response to SSRIs than will
become suicidal (Bridge et al. 2007) (option D is incorrect). (Chapter 27, Youth
Suicide/Treatment/Psychotherapy Approaches, pp. 577–580)

27.4 You evaluate a 17-year-old boy with bipolar disorder in the emergency department
because of his psychiatrist’s concern about his expressing acute suicidal thoughts.
This is the boy’s fourth visit to the emergency room in 4 weeks. What is the most
effective way to assess his suicidality?

A. Begin by asking mostly general questions about his mood, to establish rap-
port, rather than asking details about intent or preparatory behavior.
B. Elicit a social history, especially addressing any recent interpersonal challenges
with loved ones.
C. Understand more specific details about the severity of his suicidal ideation,
with less focus on the pervasiveness.
D. Clarify his relatively low intent, implying a lesser likelihood of lethality.

The correct response is option B: Elicit a social history, especially addressing

any recent interpersonal challenges with loved ones.

The most common precipitant for adolescent suicidal behavior is interpersonal

conflict or loss, most often involving a parent or a romantic relationship (option
B is correct). Suicidal ideation should be assessed according to both severity (in-
tent) and pervasiveness (frequency and intensity). Suicidal ideation characterized
by a high degree of severity and pervasiveness is associated with greater likelihood
of suicide attempt in adolescents (Lewinsohn et al. 1996) (option C is incorrect).

Youth Suicide—Answer Guide | 253

 With regard to suicidal intent, four components should be explored (Kingsbury
1993): 1) belief about intent (i.e., the extent to which the individual is wishing to
die); 2) preparatory behavior (e.g., giving away prized possessions, writing a sui-
cide note); 3) prevention of discovery (i.e., planning the attempt so that rescue is
unlikely); and 4) communication of suicidal intent (option A is incorrect). Suicide
attempts of high medical lethality (e.g., hanging, shooting) are frequently charac-
terized by high suicidal intent, and individuals who use more medically lethal
means are at higher risk to complete suicide. However, evidence also indicates that
an impulsive attempter with relatively low intent but ready access to lethal means
may also engage in a medically serious and even fatal attempt (Brent et al. 1999)
(option D is incorrect). (Chapter 27, Youth Suicide/Assessment, pp. 574–575)

27.5 Which of the following is the most accurate statement regarding suicide attempt
or completion?

A. Hispanic youth have a higher rate of suicides than American Indian youth.
B. Suicide is the third leading cause of death in youth.
C. The lifetime prevalence of suicide attempts in youth is 2.4%.
D. Rates of completed suicides in youth demonstrate a male:female ratio of 3:1.

The correct response is option B: Suicide is the third leading cause of death in
youth.

In the United States in 2010, suicide was the third leading cause of death among
youth and young adults and accounted for 11% of the mortality in this age group
(Centers for Disease Control and Prevention 2010) (option B is correct). American
Indians/Alaska Natives exhibit the highest suicide rate of all ethnic groups in the
United States (Centers for Disease Control and Prevention 2010) (option A is in-
correct). Results from a recent survey of adolescents in the United States indicate
the lifetime prevalence of suicide attempts is 4.1%, suicidal ideation with plan is 4%,
and any suicidal ideation is 12.1% (Nock et al. 2013). Yet the Youth Risk Behavior
Surveillance Study of high school students in the United States reported substan-
tially higher incidences: 7.8% of youth reported attempting suicide within the
prior year, 2.4% of whose attempts were medically serious (option C is incorrect). The
rate of completed suicide among youth is significantly higher for males than females,
with a ratio of nearly 5:1 in 2010 (Centers for Disease Control and Prevention
2010). However, females endorse higher rates of suicidal ideation (19.3% vs. 12.5%)
and have higher suicide attempt rates than males (9.8% vs. 5.8%; Eaton et al. 2012)
(option D is incorrect). (Chapter 27, Youth Suicide/Epidemiology, p. 571; Character-
istics, pp. 571–572)

References
Brent DA, Melhem N: Familial transmission of suicidal behavior. Psychiatr Clin North Am 31(2):
157–177, 2008 18439442
Brent DA, Perper JA, Goldstein CE, et al: Risk factors for adolescent suicide: a comparison of ad-
olescent suicide victims with suicidal inpatients. Arch Gen Psychiatry 45(6):581–588, 1988
3377645

254 | Youth Suicide—Answer Guide

Brent DA, Baugher M, Bridge J, et al: Age- and sex-related risk factors for adolescent suicide. J Am
Acad Child Adolesc Psychiatry 38(12):1497–1505, 1999 10596249
Brent DA, Poling KD, Goldstein TR: Treating Depressed and Suicidal Adolescents. New York,
Guilford, 2011
Bridge JA, Iyengar S, Salary CB, et al: Clinical response and risk for reported suicidal ideation and
suicide attempts in pediatric antidepressant treatment: a meta-analysis of randomized con-
trolled trials. JAMA 297(15):1683–1696, 2007 17440145
Centers for Disease Control and Prevention: Web-based Injury Statistics Query and Reporting Sys-
tem (WISQARS). Atlanta, GA, Centers for Disease Control and Prevention, 2010. Available at:
http:// www.cdc.gov/ncipc/wisqars. Accessed May 29, 2014.
Eaton DK, Kann L, Kinchen S, et al: Youth risk behavior surveillance—United States, 2011. MMWR
Surveill Summ 61(4):1–162, 2012 22673000
Emslie G, Kratochvil C, Vitiello B, et al: Treatment for Adolescents with Depression Study (TADS):
safety results. J Am Acad Child Adolesc Psychiatry 45(12):1440–1455, 2006 17135989
Gibbons RD, Brown CH, Hur K, et al: Early evidence on the effects of regulators’ suicidality warnings
on SSRI prescriptions and suicide in children and adolescents. Am J Psychiatry 164(9):1356–
1363, 2007 17728420
Huey SJ Jr, Henggeler SW, Rowland MD, et al: Multisystemic therapy effects on attempted suicide
by youths presenting psychiatric emergencies. J Am Acad Child Adolesc Psychiatry 43(2):
183–190, 2004 14726725
Kingsbury SJ: Clinical components of suicidal intent in adolescent overdose. J Am Acad Child Ado-
lesc Psychiatry 32(3):518–520, 1993 8496114
Lewinsohn PM, Rohde P, Seeley JR: Adolescent suicidal ideation and attempts: prevalence, risk
factors, and clinical implications. Clin Psychol Sci Pract 3(1):25–46, 1996
Lewis LM: No-harm contracts: a review of what we know. Suicide Life Threat Behav 37(1):50–57,
2007 17397279
March J, Silva S, Petrycki S, et al: Fluoxetine, cognitive-behavioral therapy, and their combination
for adolescents with depression: Treatment for Adolescents With Depression Study (TADS)
randomized controlled trial. JAMA 292(7):807–820, 2004 15315995
Nock MK, Green JG, Hwang I, et al: Prevalence, correlates, and treatment of lifetime suicidal be-
havior among adolescents: results from the National Comorbidity Survey Replication Ado-
lescent Supplement. JAMA Psychiatry 70(3):300–310, 2013 23303463
Rotheram-Borus MJ, Piacentini J, Cantwell C, et al: The 18-month impact of an emergency room
intervention for adolescent female suicide attempters. J Consult Clin Psychol 68(6):1081–1093,
2000 11142542
Roy A: Family history of suicide and neuroticism: a preliminary study. Psychiatry Res 110(1):87–
91, 2002 12007597
Shaffer D, Gould MS, Fisher P, et al: Psychiatric diagnosis in child and adolescent suicide. Arch
Gen Psychiatry 53(4):339–348, 1996 8634012
Stanley B, Brown G, Brent DA, et al: Cognitive-behavioral therapy for suicide prevention (CBT-SP):
treatment model, feasibility, and acceptability. J Am Acad Child Adolesc Psychiatry 48(10):
1005–1013, 2009 19730273
Suicide Prevention Resource Center: Best practices registry, 2012. Available at: http:// www.sprc.org.
Accessed May 29, 2014.

Youth Suicide—Answer Guide | 255

 C H A P T E R 2 8

Gender Dysphoria and

Nonconformity
28.1 What term or concept refers to the sex of a person to whom an individual is erot-
ically attracted?

A. Natal sex.
B. Gender identity.
C. Gender expression.
D. Sexual orientation.

The correct response is option D: Sexual orientation.

In most cases, infants are assigned at birth a natal sex of male or female on the basis
of a physician’s visual assessment of their genitalia (option A is incorrect). Gender
identity refers to an individual’s personal sense of self as male or female, which is
not assigned but is psychologically rooted (option B is incorrect). Gender expres-
sion refers to the way in which individuals communicate their gender identity
within a given culture (option C is incorrect). Sexual orientation refers to the sex of
a person “to whom an individual is erotically attracted and comprises several
components including sexual fantasy, patterns of physiological arousal, sexual
behavior, sexual identity, and social role” (Adelson and American Academy of
Child and Adolescent Psychiatry Committee on Quality Issues 2012) (option D is
correct). (Chapter 28, Gender Dysphoria and Nonconformity/Key Concepts and
Terminology, pp. 585–586)

28.2 According to cognitive theories of gender development, the majority of children

have a sense of gender identity by what age?

A. 1 year.
B. 3 years.
C. 8 years.
D. 12 years.

The correct response is option B: 3 years.

257
 According to cognitive theories of gender development, the majority of children
have a sense of gender identity by age 3 years (option B is correct; options A, C, and
D are incorrect), with most establishing a lifelong male or female gender identity
consistent with their natal sex by age 5 or 6 years. (Chapter 28, Gender Dysphoria
and Nonconformity/Key Concepts and Terminology, p. 585)

28.3 Which group is most often referred for treatment in the context of gender variance?

A. Child natal boys.

B. Child natal girls.
C. Adolescent natal boys.
D. Adolescent natal girls.

The correct response is option A: Child natal boys.

In treatment referral rates in children, natal gender differences are found. Natal
boys are more often referred for treatment in the context of gender variance than
natal girls (ratio of 5.78–2.9:1) (option A is correct; option B is incorrect). Adoles-
cent rates of referral are lower and nearly equal (1.75:1 natal boys to natal girls)
(options C and D are incorrect). (Chapter 28, Gender Dysphoria and Nonconfor-
mity/Epidemiology, p. 590)

28.4 Regarding the two factors—cognitive gender confusion and affective gender con-
fusion—measured by the Gender Identity Interview for Children (GIIC), what
was identified as the strongest predictor of persistence of gender dysphoria from
childhood into adolescence?

A. Lower cognitive gender confusion.

B. Higher cognitive gender confusion.
C. Lower affective gender confusion.
D. Higher affective gender confusion.

The correct response is option B: Higher cognitive gender confusion.

Higher levels of both cognitive gender confusion and affective gender confusion
predicted persistence of gender dysphoria into adolescence, with cognitive re-
sponses to the GIIC identified as the strongest predictor (option B is correct; op-
tions A, C, and D are incorrect), accounting for 11% of the unique variability in
persistence of gender dysphoria (Steensma et al. 2013). (Chapter 28, Gender Dys-
phoria and Nonconformity/Assessment: Psychometric Measures Across Devel-
opment, p. 595)

28.5 Based on prospective research, which of the following is true regarding the trajec-
tory of the majority of those who experience childhood gender dysphoria?

A. Gender dysphoria persists during early adolescence.

B. Gender dysphoria “desists” in adulthood.

258 | Gender Dysphoria and Nonconformity—Answer Guide

 C. As adults, these individuals are more likely to express a gender identity incon-
sistent with their natal sex.
D. As adults, these individuals more often identify as gay, lesbian, or bisexual than
as heterosexual.

The correct response is option D: As adults, these individuals more often iden-
tify as gay, lesbian, or bisexual than as heterosexual.

According to prospective research on trajectories of childhood gender variance,

gender dysphoria “desists” during early adolescence in the majority of youth (op-
tions A and B are incorrect). These youth as adults are more likely to express a
gender identity consistent with their natal sex (option C is incorrect) and more of-
ten identify as gay, lesbian, or bisexual than as heterosexual (option D is correct).
Adolescents for whom gender dysphoria does not desist around puberty are more
likely to experience persistent gender dysphoria into adulthood. (Chapter 28,
Gender Dysphoria and Nonconformity/Overview of Gender and Sexuality De-
velopment, p. 591)

References
Adelson SL, American Academy of Child and Adolescent Psychiatry Committee on Quality Is-
sues: Practice parameter on gay, lesbian, or bisexual sexual orientation, gender nonconformity,
and gender discordance in children and adolescents. J Am Acad Child Adolesc Psychiatry
61(9):957–974, 2012 22917211
Steensma TD, McGuire JK, Kreukels BPC, et al: Factors associated with desistence and persistence
of childhood gender dysphoria: a quantitative follow-up study. J Am Acad Child Adolesc
Psychiatry 52(6):582–590, 2013 23702447

Gender Dysphoria and Nonconformity—Answer Guide | 259

 C H A P T E R 2 9

Aggression and Violence

29.1 What is typically meant by the term predatory aggression?

A. Attempting to cause pain to the victim with no independent gain.

B. Goal-directed behavior that offers some benefit to the aggressor.
C. Deliberate, controlled aggression.
D. Impetuous, poorly controlled aggression.

The correct response is option C: Deliberate, controlled aggression.

Numerous subtypes of aggression have been described, but most classification

schemes dichotomize aggression with respect to the ability to modulate and con-
trol the behavior and/or the intended goal. Examples of subtypes include the fol-
lowing: proactive (i.e., goal-directed, usually associated with leadership skills
and positive peer perceptions) (option B is incorrect) versus reactive (i.e., re-
sponding to a threat, retaliating); predatory (i.e., deliberate, controlled) (option C
is correct) versus affective (i.e., impetuous, poorly controlled) (option D is incor-
rect); and instrumental (implies goal-directed behavior that offers some benefit to
the aggressor) versus hostile (attempting to cause pain to the victim with no inde-
pendent gain) (option A is incorrect). (Chapter 29, Aggression and Violence/
Definition and Clinical Description, pp. 603–604)

29.2 Prosocial aggression (e.g., male dominance) appears to be heavily influenced by

_______________, while impulsive aggression is more consistently related to
______________.

A. Serotonin (5-HT), testosterone.

B. Norepinephrine, 5-HT.
C. Testosterone, norepinephrine.
D. Testosterone, 5-HT.

The correct response is option D: Testosterone, 5-HT.

The different types of aggression appear to be associated with distinct neurobio-

logical mechanisms. Prosocial aggression (e.g., male dominance) appears to be

261
 heavily influenced by testosterone, while impulsive aggression is more consistently
related to 5-HT (option D is correct). The role of catecholamines in pathological
(not prosocial or impulsive) aggression is likely attributable to norepinephrine re-
ceptors in both the central nervous system and the autonomic nervous system,
with characteristic findings in relation to physiological measures of arousal (op-
tions B and C are incorrect). Option A is incorrect as it is the reverse of the correct
answer. (Chapter 29, Aggression and Violence/Etiology, Mechanisms, and Risk
Factors, p. 605)

29.3 Cerebrospinal fluid levels of what metabolite have been inversely correlated with
measures of aggressive behavior in both male and female primates?

A. 5-Hydroxyindoleacetic acid (5-HIAA).

B. Norepinephrine.
C. Serotonin (5-HT).
D. Dopamine.

The correct response is option A: 5-Hydroxyindoleacetic acid (5-HIAA).

Convergent data from studies in animals and human adults have linked aggres-
sive behaviors to abnormalities in neurotransmission mediated by 5-HT and the
catecholamines (i.e., dopamine and norepinephrine). Inhibition of 5-HT synthe-
sis, depletion of 5-HT stores, or destruction of 5-HT neurons can produce aggres-
sive behavior. Cerebrospinal fluid levels of the 5-HT metabolite 5-HIAA have
been shown to be inversely correlated with measures of aggressive behavior in
both male and female primates (option A is correct; option C is incorrect). In ad-
dition, low 5-HT function early in life predicts excessive aggression, risk taking,
and premature death in nonhuman male primates. The role of catecholamines
(i.e., dopamine and norepinephrine) in pathological aggression is likely attribut-
able to norepinephrine receptors in both the central nervous system and the au-
tonomic nervous system, with characteristic findings in relation to physiological
measures of arousal (options B and D are incorrect). (Chapter 29, Aggression and
Violence/Etiology, Mechanisms, and Risk Factors/Neurochemistry, p. 605–606)

29.4 What is the candidate gene that codes for a transporter receptor that is most con-
sistently linked to aggression?

A. Dopamine transporter.
B. Norepinephrine transporter.
C. Serotonin (5-HT) transporter.
D. Testosterone transporter.

The correct response is option C: Serotonin (5-HT) transporter.

The candidate genes most consistently linked to aggression are the 5-HT trans-
porter gene (5-HTT) (option C is correct) and the genes for three enzymes that have
an important role in the homeostasis, inactivation, and clearance of dopamine and

262 | Aggression and Violence—Answer Guide

 norepinephrine: monoamine oxidase, catechol O-methyltransferase, and dopamine
β-hydroxylase (Pedraza et al. 2012). The dopamine (option A), norepinephrine
(option B), and testosterone transporters (option D) are incorrect nomenclature.
(Chapter 29, Aggression and Violence/Genetic Factors/Candidate Genes, pp.
606–607)

29.5 Findings suggest that what type of violence exposure is the most robust predictor
of externalizing problems?

A. Witnessing violence against familiars.

B. Being directly exposed to violence.
C. Hearing reports of aggression toward familiars.
D. Hearing reports of aggression toward strangers.

The correct response is option B: Being directly exposed to violence.

The occurrence of high-visibility incidents of youth violence in schools (e.g., Col-

umbine High School and Heritage High School shootings) highlights the link be-
tween community factors and aggression. Studies have differentiated among
multiple types of community violence exposure, including direct violence, wit-
nessing, and hearing reports of aggression against familiars and/or strangers.
Findings suggest that direct violence exposure is the most robust predictor of
externalizing problems, although witnessing violence against familiars is also a
robust predictor, particularly for girls (Javdani et al. 2014) (option B is correct; op-
tions A, C, and D are incorrect). (Chapter 29, Aggression and Violence/Social-
Emotional Factors/Community and Social Factors, p. 608)

29.6 What is the best-studied and best-validated treatment for youth aggression?

A. Cognitive-behavioral therapy.
B. Multidimensional Treatment Foster Care.
C. Behavioral parent training.
D. Multisystemic treatment.

The correct response is option C: Behavioral parent training.

Empirically supported psychosocial interventions target one or more of the be-

haviors that characterize (e.g., verbal aggression, property destruction, physical
aggression) or serve to maintain (e.g., affect regulation, social information pro-
cessing deficits, coercive parenting behaviors) aggressive behavior. Behavioral
parent training is the best-studied and best-validated treatment for youth aggres-
sion (option C is correct). Behavioral parent training attempts to break the coer-
cive reinforcement cycle between parents and their children that contributes to
the development and proximal maintenance of aggressive behaviors. Cognitive-
behavioral therapy has also been used successfully (option A is incorrect). Given
the limitations of single interventions for youth with the greatest severity of aggres-
sion risk, multimodal approaches are often necessary. Substantial evidence sup-

Aggression and Violence—Answer Guide | 263

 ports multisystemic treatment and Multidimensional Treatment Foster Care for
high-risk youth with aggressive, antisocial behavior (options B and D are incorrect).
(Chapter 29, Aggression and Violence/Treatment/Psychotherapeutic Treatments,
pp. 614–615)

References
Javdani S, Abdul-Adil J, Suarez L, et al: Gender differences in the effects of community violence
on mental health outcomes in a sample of low-income youth receiving psychiatric care. Am J
Community Psychol 53(3–4):235–248, 2014 24496719
Pedraza J, Ivanov I, Otoy O, et al: Functional genetic variations and their role in aggressive be-
havior in the context of disruptive behavior disorders, in Advances in Psychology Research,
Vol 95. Edited by Columnus AM. New York, NOVA Publishing, 2012, pp 118–138

264 | Aggression and Violence—Answer Guide

 C H A P T E R 3 0

Psychiatric Emergencies
30.1 Research consistently finds which of the following two are among the most salient
risk factors for future suicide attempts?

A. Substance abuse and recent loss.

B. Suicidal ideation and poor social supports.
C. Being a victim of physical or sexual abuse and having poor impulse control.
D. Suicidal ideation and history of suicide attempts.

The correct response is option D: Suicidal ideation and history of suicide attempts.

The assessment of the suicidal patient includes risk factors for future suicidal ac-
tions (see Table 30–1). Research consistently finds that suicidal ideation and a his-
tory of suicide attempts are among the most salient risk factors for future suicide
attempts (option D is correct). The assessment of the suicidal patient should thus
focus on the severity of ideation and the lethality and intent of action. Suicidal
ideation and poor social supports, while both risk factors for future suicide at-
tempts, is incorrect because a history of suicide attempts is a stronger risk factor
for suicide than poor social supports (option B is incorrect). Furthermore, sub-
stance abuse and recent loss (option A is incorrect) and being a victim of physical
or sexual abuse and having poor impulse control (option C is incorrect) are all risk
factors for future suicide attempts, but not as salient as suicidal ideation and his-
tory of suicide attempts. (Chapter 30, Psychiatric Emergencies/Common Clini-
cal Presentations/Suicidal Behavior, p. 622; Table 30–1, p. 623)

30.2 Which of the following is a concise screening instrument that can be used to
screen for substance use in the emergency department (ED) setting?

A. Children’s Depression Inventory (CDI).

B. CRAFFT.
C. Patient Health Questionnaire–9 (PHQ-9).
D. Screen for Child Anxiety Related Emotional Disorders (SCARED).

The correct response is option B: CRAFFT.

265
TABLE 30–1. Risk factors for a suicide attempt
Patient history
Verbalization or threats regarding suicide
Substance abuse
Poor impulse control
Recent loss or other severe stressor
Previous suicide attempt(s)
Friend or family member who has committed suicide
Exposure to recent news stories or movies about suicide
Poor social supports
Victim of physical or sexual abuse
Nature of the attempt
Accidental discovery (vs. attempt in view of others or telling others immediately)
Careful plans to avoid discovery
Hanging or gunshot
Family
Wishes to be rid of child or adolescent
Does not take child’s problems seriously
Is overly angry and punitive
Depression or suicidality is present in a family member
Is unwilling or unable to provide support and supervision
Mental status examination
Depression
Hopelessness
Regret at being rescued
Belief that things would be better for self or others if dead
Wish to rejoin a dead loved one
Belief that death is temporary and pleasant
Unwillingness to promise to call before attempting suicide
Psychosis
Intoxication

Clinicians do not recognize alcohol use in as many as 50% of the patients who even-
tually test positive in the ED. The inability to identify these patients is due not
only to a reluctance to pursue the issue aggressively but also because ED staff do
not routinely use quick and effective means of case identification. Concise screen-
ing instruments such as the Drug Abuse Screening Test (DAST) or the CRAFFT
screening test must accompany the interview and any indicated laboratory stud-
ies in the ED (Burke et al. 2005; Yudko et al. 2007) (option B is correct). Structured
tools such as the Patient Health Questionnaires (PHQ-2 and PHQ-9) are effective
in identifying parental depression (Olson et al. 2006) (option C is incorrect). Exam-
ples of rating scales specifically for internalizing disorders are the Children’s De-
pression Inventory (CDI) and Screen for Child Anxiety Related Emotional
Disorders (SCARED) (options A and D are incorrect). (Chapter 30, Psychiatric

266 | Psychiatric Emergencies—Answer Guide

 Emergencies/Common Clinical Presentations/Substance Abuse, p. 626; Chapter
2, Assessing Infants and Toddlers/Formal Assessment Procedures/Parent Screen-
ing, p. 30; Chapter 4, Assessing the Elementary School-Age Child/Assessment
Tools, p. 68)

30.3 What is the most commonly recommended medication for patients with delirium
in the pediatric emergency department?

A. Risperidone.
B. Olanzapine.
C. Quetiapine.
D. Lorazepam.

The correct response is option A: Risperidone.

The most effective treatment for delirium is the correction of the underlying med-
ical cause of the disorder, although patients often present with multiple causes
that are not easily identified or controlled. When resolution of the primary cause
is not possible, the clinician treats the symptoms in order to ease distress in the
patient and the family and improve medical outcome (American Psychiatric Asso-
ciation 1999). Antipsychotic medications are recommended when the symptoms are
persistent and severe and affect the child’s medical outcome. High-potency first-
generation antipsychotics are known to be effective on the basis of controlled tri-
als in adults using standardized assessments. Atypical antipsychotics are now more
often recommended, primarily because of their lower risk of extrapyramidal side
effects. Risperidone is the most commonly used (Preval et al. 2005; Sipahimalani
and Masand 1998) (option A is correct; options B and C are incorrect). Benzodiaz-
epines alone (e.g., lorazepam) are rarely effective in children and may complicate
or exacerbate symptoms of delirium (option D is incorrect). (Chapter 30, Psychi-
atric Emergencies/Common Clinical Presentations/Delirium, pp. 628–629)

30.4 Which medication class has demonstrated efficacy in the treatment of aggression
and self-injurious behavior in intellectually and developmentally delayed patients
as well as the treatment of adolescent aggression across psychiatric diagnoses?

A. Typical antipsychotics.
B. Atypical antipsychotics.
C. Benzodiazepines.
D. Antihistamines.

The correct response is option B: Atypical antipsychotics.

Historically, benzodiazepines, haloperidol, and antihistamines have been used

most commonly to treat agitation in both adult and pediatric settings (Baeza et al.
2013; Dorfman and Kastner 2004; Marzullo 2014). However, in the pediatric pop-
ulation, there are concerns about benzodiazepines and antihistamines causing
paradoxical reactions (options C and D are incorrect). There is also a trend toward

Psychiatric Emergencies—Answer Guide | 267

 choosing second-generation agents over first-generation agents because of the lower
risk of extrapyramidal side effects (option A is incorrect). Atypical antipsychotics
have demonstrated efficacy in the treatment of aggression and self-injurious be-
havior in intellectually and developmentally delayed patients as well as the treat-
ment of adolescent aggression across psychiatric diagnoses, with a number needed to
treat of 2–5 (Baeza et al. 2013) (option B is correct). (Chapter 30, Psychiatric Emer-
gencies/Management of the Aggressive Pediatric Patient/Pharmacological In-
terventions, p. 632)

30.5 Which of the following interventions is agreed on by most experts as the first in-
tervention when managing aggression?

A. Behavioral approaches.
B. Seclusion.
C. Restraint.
D. Pharmacological interventions.

The correct response is option A: Behavioral approaches.

Circumstances in the emergency department often dictate the course of treatment

and the techniques used to manage the patient with agitation (Masters et al. 2002).
Most experts agree that behavioral approaches (option A is correct) to aggression
should be used first. The use of seclusion (option B is incorrect) and restraint (op-
tion C is incorrect) is a frequent intervention with aggressive and potentially dan-
gerous patients; however, their effectiveness in the pediatric population is largely
unknown and remains controversial (De Hert et al. 2011). Pharmacological in-
terventions (option D is incorrect) aimed at reducing aggression in the pediatric
emergency setting are quite common, although there are limited data on their use).
(Chapter 30, Psychiatric Emergencies/Management of the Aggressive Pediatric
Patient/Seclusion and Restraint/Pharmacological Interventions, pp. 631–632)

References
American Psychiatric Association: Practice guideline for the treatment of patients with delirium.
Am J Psychiatry 156(5 suppl):1–20, 1999 10327941
Baeza I, Correll C, Saito E, et al: Frequency, characteristics and management of adolescent inpa-
tient aggression. J Child Adolesc Psychopharmacol 23(4):271–281, 2013 23647136
Burke PJ, O’Sullivan J, Vaughan BL: Adolescent substance use: brief interventions by emergency
care providers. Pediatr Emerg Care 21(11):770–776, 2005 16280955
De Hert M, Dirix N, Demunter H, Correll CU: Prevalence and correlates of seclusion and restraint
use in children and adolescents: a systematic review. Eur Child Adolesc Psychiatry 20(5):221–
230, 2011 21298305
Dorfman DH, Kastner B: The use of restraint for pediatric psychiatric patients in emergency de-
partments. Pediatr Emerg Care 20(3):151–156, 2004 15094571
Marzullo LR: Pharmacologic management of the agitated child. Pediatr Emerg Care 30(4):269–275,
quiz 276–278, 2014 24694885

268 | Psychiatric Emergencies—Answer Guide

Masters KJ, Bellonci C, Bernet W, et al: Practice parameter for the prevention and management of
aggressive behavior in child and adolescent psychiatric institutions, with special reference to
seclusion and restraint. J Am Acad Child Adolesc Psychiatry 41 (2 suppl):4S–25S, 2002
11833634
Olson AL, Dietrich AJ, Prazar G, et al: Brief maternal depression screening at well-child visits. Pe-
diatrics 118(1):207–216, 2006 16818567
Preval H, Klotz SG, Southard R, et al: Rapid-acting IM ziprasidone in a psychiatric emergency ser-
vice: a naturalistic study. Gen Hosp Psychiatry 27(2):140–144, 2005 15763126
Sipahimalani A, Masand PS: Olanzapine in the treatment of delirium. Psychosomatics 39(5):422–
430, 1998 9775699
Yudko E, Lozhkina O, Fouts A: A comprehensive review of the psychometric properties of the
Drug Abuse Screening Test. J Subst Abuse Treat 32(2):189–198, 2007 17306727

Psychiatric Emergencies—Answer Guide | 269

 C H A P T E R 3 1

Family Transitions
Challenges and Resilience
31.1 To foster immediate and long-term adaptation for children after the death of a
family member, what should the psychiatrist recommend to the family?

A. Share acknowledgment of the reality of death and loss through information and
communication.
B. Stop memorial rituals.
C. Continue the same relationships and role functions among family members.
D. Focus on maintaining bonds with the deceased as a living presence.

The correct response is option A: Share acknowledgment of the reality of death

and loss through information and communication.

Family adaptation to loss involves sharing grief, gaining meaning and perspec-
tive, and moving ahead with life. Four core family tasks facilitate immediate and
long-term adaptation for children and strengthen the family as a functional unit
(Walsh and McGoldrick 2004, 2013): 1) Share acknowledgment of the reality of
death and loss through information and communication (option A is correct).
2) Share experience of loss via memorial rituals and empathic sharing of feelings
and meaning-making (option B is incorrect). 3) Reorganize family system through
restabilization and realignment of relationships and role functions to provide
continuity, cohesion, and adaptive flexibility (option C is incorrect). 4) Reinvest in
relationships and life pursuits and transform bonds with the deceased from living
presence to spiritual connections, memories, and legacies (option D is incorrect).
(Chapter 31, Family Transitions: Challenges and Resilience/Highly Disruptive
Family Transitions/Adaptation to Death and Loss/Facilitating Adaptation to
Loss, pp. 643–644)

31.2 What could an adoptive parent do to help an adopted child benefit developmen-
tally?

A. Deny contact with the birth family.

B. Acclimate the child only to the culture of the adoptive parent.

271
 C. Participate in an open adoption.
D. Establish that the adoptive parent is not the “natural” parent.

The correct response is option C: Participate in an open adoption.

Most adoptions are now open, on the basis of findings that children benefit devel-
opmentally if they know who their birth families are (option C is correct), have
the option for contact (option A is incorrect), and in biracial and international
adoption children are encouraged to develop bicultural identities and connec-
tions (option B is incorrect). It is inadvisable to regard a stepparent or adoptive
parent as not the “real” or “natural” parent (option D is incorrect). (Chapter 31,
Family Transitions: Challenges and Resilience/Family Transformations in a
Changing Society/Changing Family Structures and Gender Roles, p. 638)

31.3 A 12-year-old girl is the daughter of immigrants from Thailand. The family lives
in a middle-class community with her aunts, uncles, and cousins. Her parents
have college educations and both are working; her father has needed to change
jobs three times in the last year. What factor is the most challenging to their resil-
ience in the setting of immigration?

A. Father’s recurring job transitions.

B. Availability of family.
C. Parents’ education level.
D. Having both parents work.

The correct response is option A: Father’s recurring job transitions.

Strong kinship bonds foster resilience (option B is incorrect), particularly for im-
migrants struggling to overcome conditions of poverty. Those with limited edu-
cation (option C is incorrect), job skills, and employment opportunities (option D
is incorrect) have been hit hardest. Persistent unemployment or recurring job
transitions (option A is correct) can fuel substance abuse, relational conflict and
violence, family breakup, loss of homes, and an increase in poor single-parent
households. (Chapter 31, Family Transitions: Challenges and Resilience Family
Transformations in a Changing Society/Cultural Diversity and Socioeconomic
Disparity, pp. 638–639)

31.4 Which family transition is considered the most manageable?

A. Loss of a parent’s job.

B. Adoption of a child.
C. Divorce.
D. Parental illness.

The correct response is option B: Adoption of a child.

Anticipated family developmental transitions are more manageable than unex-

pected changes, yet they are stressful because family structures must adapt to meet

272 | Family Transitions—Answer Guide

 emerging needs and priorities. With the birth or adoption of a child (option B is
correct), parents must reorganize their lives. Nonnormative—unanticipated and
untimely—family transitions are highly disruptive in family life. The loss of a
breadwinner’s job or a parent’s life-threatening illness can generate anxiety and
family upheaval (options A and D are incorrect). Transitions with divorce require at-
tention to loss for positive adaptation (option C is incorrect). (Chapter 31, Family
Transitions: Challenges and Resilience/Childrearing Phases: Expectable De-
velopmental Transitions, p. 640; Highly Disruptive Family Transitions, p. 641)

31.5 Jim was divorced and then married Betty. They have two children together (10 years
old and 5 years old), and Jim’s daughter (14 years old) from his previous marriage
lives with them. Betty and her stepdaughter have a tumultuous relationship. Jim
and Betty recently have had a miscarriage. What factor does not contribute to
their risk of divorce?

A. Jim’s previous divorce.

B. Their miscarriage.
C. This being Betty’s first marriage.
D. The relationship between Betty and her stepdaughter.

The correct response is option C: This being Betty’s first marriage.

Divorce rates, after rising in recent decades, have leveled off for first marriages
(Amato 2010) (option C is correct). Difficulties in combining households and forg-
ing new steprelationships contribute to the high divorce rate for remarriages (op-
tions A and D are incorrect). The loss of a child places the parents’ relationship at
risk for conflict and divorce if they withdraw, grieve separately, or blame each
other (option B is incorrect). (Chapter 31, Family Transitions: Challenges and
Resilience/Family Transformations in a Changing Society/Changing Family
Structures and Gender Roles, p. 638; Highly Disruptive Family Transitions/
Death of a Child or Sibling, p. 643)

31.6 Which of these situations is an ambiguous loss?

A. Miscarriage.
B. Homicide.
C. Dementia.
D. Lingering death.

The correct response is option C: Dementia.

The nature and circumstances of loss can increase risk of child and family dys-
function. Ambiguous loss occurs when there is lack of clarity about the fate of a
loved one who is missing or when there is psychological and relational loss of a
loved one who is still alive, as in dementia (option C is correct). Miscarriage is an
example of a disenfranchised loss, specifically a socially unacknowledged loss (op-
tion A is incorrect). Homicide is an example of a violent death (option B is incorrect).

Family Transitions—Answer Guide | 273

 Lingering death, such as after a long illness, depletes family resources and gener-
ates both relief and guilt that a prolonged ordeal is over (option D is incorrect).
(Chapter 31, Family Transitions: Challenges and Resilience/Highly Disruptive
Family Transitions/Variables in Child and Family Risk, p. 642)

31.7 Which scenario involves the clinician using a resilience-oriented approach?

A. Encouraging a parent and child to reach a hierarchical understanding.

B. Focusing on negative influences of substance abuse.
C. Facilitating the creation of a bicultural identity in the setting of migration.
D. Promoting passive acceptance in the setting of transitions.

The correct response is option C: Facilitating the creation of a bicultural identity

in the setting of migration.

In a resilience-oriented assessment (Walsh 2003), it is important to identify pro-

cesses that promote resilience, such as active coping (option D is incorrect) and
perseverance, and to draw out stories of positive adaptation in facing other life
challenges. Resilience is fostered by weaving together a bicultural identity (op-
tion C is correct), sustaining cultural continuities, and affective bonds that bolster
health and mental health when coping with migration stresses (Falicov 2012,
2013). When therapy is overly problem focused, it grimly replicates the family’s
problem-saturated experience (option B is incorrect). Reaching greater mutual
understanding between parent and child is a part of the resilience-oriented ap-
proach (option A is incorrect). (Chapter 31, Family Transitions: Challenges and
Resilience/Family Systems–Oriented Practice, p. 640; Highly Disruptive Fam-
ily Transitions, pp. 646–647)

31.8 A child is removed from the home to protect him from abuse. Which intervention
is consistent with a collaborative resilience-oriented approach?

A. Reinforce that the decisions are out of the family’s control.

B. Mobilize the kin network to provide input on a safe option.
C. Reinforce separation of foster and kin networks.
D. Discontinue sessions after the child returns to his parent.

The correct response is option B: Mobilize the kin network to provide input on
a safe option.

By involving family members in placement decisions, they are more likely to sup-
port the best arrangement for children (option B is correct). This process reduces
the sense that children are being removed by outside forces beyond family con-
trol, such as arbitrary court decisions (option A is incorrect). With placement,
maintaining the continuity of significant relationships for children is a priority.
On the child’s return to parents, occasional contact from a former foster family
helps the child integrate the experience (option C is incorrect). Recidivism in child
placements is high. It is critical to plan the transition back to parents carefully

274 | Family Transitions—Answer Guide

 (Minuchin et al. 2007). Clinicians need to address the disruption and shifts in role
relations, so follow-up sessions are crucial (option D is incorrect). (Chapter 31,
Family Transitions: Challenges and Resilience/Highly Disruptive Family Tran-
sitions/Families and Foster or Kinship Care, pp. 648–649)

References
Amato P: Research on divorce: continuing trends and new developments. J Marriage Fam 72(3):
650–666, 2010
Falicov CJ: Immigrant family processes: a multidimensional framework, in Normal Family Pro-
cesses, 4th Edition. Edited by Walsh F. New York, Guilford, 2012, pp 297–323
Falicov CJ: Latino Families in Therapy: A Guide to Multicultural Practice, 2nd Edition. New York,
Guilford, 2013
Minuchin P, Colapinto J, Minuchin S: Working With Families of the Poor, 2nd Edition. New York,
Guilford, 2007
Walsh F: Family resilience: a framework for clinical practice. Fam Process 42(1):1–18, 2003 12698595
Walsh F, McGoldrick M (eds): Living Beyond Loss: Death in the Family, 2nd Edition. New York,
WW Norton, 2004
Walsh F, McGoldrick M: Bereavement: a family life cycle perspective. Special Issue, Bereavement:
Family Perspectives. Family Science 4(1):20–27, 2013

Family Transitions—Answer Guide | 275

 C H A P T E R 3 2

Legal and Ethical Issues

32.1 In which landmark case did the court decision state, “So long as the child is part
of a viable family his own interests are merged with those of the other members”?

A. Santosky v. Kramer (455 U.S. 745 [1982]).

B. Tarasoff v. Regents of the University of California (551 P.2d 334 [1976]).
C. Finlay v. Finlay (148 N.E. 624 [N.Y. ct. app. 1925]).
D. Dusky v. United States (362 U.S. 402 [1960]).

The correct response is option A: Santosky v. Kramer (455 U.S. 745 [1982]).

In the United States, contemporary society’s perception and treatment of minors

continues to reflect the traditional legal doctrines of parens patriae and the twenti-
eth-century articulation of “the best interests of the child.” Parens patriae tradition-
ally has empowered state initiatives to protect persons who are unable to care for
or protect themselves—and also has allowed state agencies to interfere with pa-
rental prerogatives when there is evidence of neglect, inability to perform paren-
tal responsibilities, or abuse of minors. This evolving interface is reflected in the
U.S. Supreme Court decision noted in Santosky v. Kramer (455 U.S. 745 [1982]): “So
long as the child is part of a viable family his own interests are merged with those
of the other members. Only after the family fails in its functions should the child’s
interests become a matter for state intrusion” (option A is correct). Imminent risk
to any individual carries a legal obligation to warn the potential target (i.e., Tara-
soff decision), although state laws vary and advice should be sought (option B is
incorrect). Articulating and prioritizing children’s needs evolved at the turn of the
twentieth century and was articulated by Judge Benjamin Cardozo as specifying
the court’s role to serve as parens patriae and do “what is in the best interests of the
child” (Finlay v. Finlay [148 N.E. 624 (N.Y. ct. app. 1925)]) (option C is incorrect).
While the U.S. Supreme Court’s decision in Dusky v. United States (362 U.S. 402
[1960]) set the standard for competency as “whether a defendant has sufficient
present ability to consult with his lawyer within a reasonable degree of rational
understanding and whether he has a rational as well as factual understanding of
the proceedings against him,” recent research in this area has clarified the neuro-
developmental processes relevant for adjudicative competency and provided an
evaluation format for assessing these processes (Grisso 2005) (option D is incorrect).

277
 (Chapter 29, Aggression and Violence/Evaluation: Clinical Assessment, p. 611;
Chapter 32, Legal and Ethical Issues/Evolving Concepts of the Status of Chil-
dren, pp. 654–655; Recent Forensic Issues in Juvenile Court, p. 661)

32.2 Which ethical principle relates to the allocation of resources and fair and equitable
distribution of risks and benefits?

A. Beneficence.
B. Justice.
C. Equipoise.
D. Autonomy.

The correct response is option B: Justice.

Ethical guidelines are evolving to highlight several principal issues: respect for
the patient’s autonomy, beneficence, and justice (option B is correct). The concept
of respect for the person’s autonomy includes informed consent in treatment and
research, including maintaining appropriate professional boundaries and confi-
dences, as well as factual honesty and avoidance of misrepresentations (option D
is incorrect). The concept of beneficence expands the “do no harm” concept to in-
clude acting in the patient’s best interests and minimizing risks and maximizing
benefits in professional judgments and relationships (option A is incorrect). Equi-
poise means that there is genuine uncertainty in the expert medical community
over whether a treatment will be beneficial (option C is incorrect). (Chapter 32,
Legal and Ethical Issues/Ethical Issues in Clinical Practice and Research, p. 655)

32.3 Which best describes the duty of confidentiality?

A. The patient’s right to prevent disclosure of information obtained during treat-

ment in judicial or quasi-judicial proceedings.
B. The clinician’s obligation to obtain consent from a minor before reporting child
neglect.
C. The clinician’s obligation to avoid disclosure of the patient’s information to any
person other than the patient.
D. The emancipated patient’s right to give consent for his or her own treatment.

The correct response is option C: The clinician’s obligation to avoid disclosure

of the patient’s information to any person other than the patient.

Privilege refers to the patient’s right to prevent disclosure of information obtained

during treatment in judicial or quasi-judicial proceedings (option A is incorrect).
The term confidentiality is broader and refers to the clinician’s obligation to avoid
disclosure of the patient’s information to any person other than the patient (op-
tion C is correct). The right of confidentiality is automatically waived when the
patient is a threat to self or others or when a reportable condition is revealed such
as sexual abuse, neglect, maltreatment, or physical abuse (option B is incorrect).
States provide various statutory exceptions to the general requirement of parental

278 | Legal and Ethical Issues—Answer Guide

 consent. For example, emancipated minors can consent to their own treatment
(option D is incorrect). (Chapter 32, Legal and Ethical Issues/Legal Issues in
Clinical Practice/Confidentiality, Privilege, and Duty, pp. 656–657)

32.4 Which standard governs the termination of parental rights?

A. Clear and convincing evidence.

B. Beyond a reasonable doubt.
C. Reasonable degree of medical certainty.
D. Preponderance of the evidence.

The correct response is option A: Clear and convincing evidence.

The standard of proof is the level of certainty required for a certain judicial out-
come, which varies depending on the type of legal proceeding. For example, the
standard of a preponderance of evidence is used in most civil proceedings (that
do not involve deprivation of fundamental rights or liberties) (option D is incor-
rect). The intermediate standard of “clear and convincing evidence” is required in
cases where a deprivation of fundamental rights or liberty is at stake, such as ter-
mination of parental rights (option A is correct). The highest standard of proof,
“beyond a reasonable doubt,” is used in criminal proceedings as well as juvenile
court and delinquency proceedings (option B is incorrect). Physicians who testify
in court typically state their opinions within a reasonable degree of medical cer-
tainty (option C is incorrect). (Chapter 32, Legal and Ethical Issues/Overview of
the Legal System, p. 660)

Reference
Grisso T: Evaluating Juvenile Adjudicative Competence: A Guide for Clinical Practice. Sarasota,
FL, Professional Resources Press, 2005

Legal and Ethical Issues—Answer Guide | 279

 C H A P T E R 3 3

Telemental Health
33.1 Which of the following statements is true regarding telemental health (TMH)?

A. TMH is part of mental health services that use secure, real-time, interactive,
two-way videoconferencing technology.
B. TMH involves any services that utilize low-grade technology to improve com-
munication with patients.
C. TMH is used only by primary care physicians to consult with mental health
providers.
D. TMH allows patients and families to post mental health questions online to be
answered over a period of days to weeks.

The correct response is option A: TMH is part of mental health services that use
secure, real-time, interactive, two-way videoconferencing technology.

TMH focuses on live, interactive, two-way videoconferencing (VC) (option A is

correct; option D is incorrect). Mobile health is narrowly included, specific to mo-
bile-based VC. Technological advances in VC systems have made secure, inex-
pensive, user-friendly, reliable VC more available (option A is correct). For VC
services, the teleprovider and distant site must have access to 1) modern, well-
functioning VC equipment, including camera, monitor, microphone, and speak-
ers (option B is incorrect); 2) encrypted VC software; 3) secure clinical space for
the equipment setup; and 4) high-speed connectivity with consistent quality of
service. Initially, TMH programs were developed to bring specialty care to pa-
tients in rural areas, often in consultation to primary care. Various models have
been used for responding to referrals from primary care providers, such as direct
assessment and treatment by the teleprovider, assessment followed by treatment
recommendations for primary care providers and local therapists to carry out,
and a stabilization model (option C is incorrect). (Chapter 33, Telemental Health/
Technical Aspects of Telemental Health, p. 670; Development of Child and Ado-
lescent Telemental Health Programs/Telemental Health Programs, p. 674)

281
33.2 How does telemental health (TMH) address possible challenges in providing mental
health services to adolescents in underserved areas?

A. TMH focuses on the significant difference in diagnoses evaluated through vid-

eoconferencing (VC) and in usual outpatient practices.
B. TMH allows patients to be evaluated in their own communities.
C. TMH systems provide all infrastructures needed to implement VC services.
D. TMH arranges transportation to distant health centers that provide mental health
treatment.

The correct response is option B: TMH allows patients to be evaluated in their

own communities.

Most behavioral health diagnoses across the developmental spectrum have been
evaluated through VC consistent with their evaluation in usual outpatient prac-
tices (option A is incorrect). Youth living in underserved communities often differ
in their racial and ethnic heritage from their clinical providers (Myers et al. 2004).
TMH allows these individuals to be evaluated in their own communities accom-
panied by family or community members who may provide context and perspec-
tive that are not available if services are provided in distant health centers (option
B is correct; option D is incorrect). Mental health centers and other child-serving
facilities may provide infrastructure that facilitates the implementation of VC ser-
vices. Many schools are seeking to understand their students’ mental health
needs and are willing to use their VC systems to access TMH services (option C
is incorrect). (Chapter 33, Telemental Health/Development of Child and Adoles-
cent Telemental Health Programs, pp. 673–674)

33.3 Which of the following statements is true about research supporting the effective-
ness of telemental health (TMH) for adolescents?

A. The body of literature supporting child and adolescent TMH is equal to the adult
literature.
B. No studies have been done to support the effectiveness of TMH in children
and adolescents.
C. All the studies have been randomized, double-blind trials.
D. The majority of reports of TMH with children and adolescents are descriptive
and address feasibility of TMH in increasing access to service.

The correct response is option D: The majority of reports of TMH with children
and adolescents are descriptive and address feasibility of TMH in increasing
access to service.

Although the body of literature supporting child and adolescent TMH has grown
substantially since 2000, it lags behind the adult literature (option A is incorrect).
A majority of the reports of TMH with children and adolescents are descriptive
and address feasibility of and/or satisfaction with TMH in increasing access to
service (option D is correct). Attitudes toward TMH have been shown to be posi-

282 | Telemental Health—Answer Guide

 tive for providers, referring physicians, families, and youth. Although still limited,
the evidence base for TMH with youth now includes outcome studies (options B
and C are incorrect). (Chapter 33, Telemental Health/Development of Child and
Adolescent Telemental Health Programs, pp. 674–676)

33.4 Which of the following is a true statement about a virtual clinical encounter?

A. A high-quality video signal is crucial to the success of a virtual encounter.

B. Confidentiality is not a key concern during a virtual encounter.
C. Only the child or adolescent and his or her family should be present during an
encounter.
D. The size of the room at the patient site does not matter.

The correct response is option A: A high-quality video signal is crucial to the

success of a virtual encounter.

A high-quality video signal is crucial to the success of the virtual encounter (op-
tion A is correct). One important factor in determining quality is adequate band-
width for high-resolution video. Confidentiality is a primary concern. Both the
interview room at the patient site and clinician’s room at the provider site should
be maintained as confidential space (option B is incorrect). A clinical staff person
at the patient site may attend the session or be immediately available to assist
with technology, provide immediate help to maintain safety, and ensure continu-
ity of care (option C is incorrect). The room at the patient site should be the right
size, neither too small nor too large. An ideal room is large enough to accommo-
date the youth, a clinical staff person, and at least two adults but not so large that
it encourages distractibility or hyperactivity (option D is incorrect). (Chapter 33,
Telemental Health/Clinical Practice of Telemental Health/Optimizing the Vir-
tual Clinical Encounter, p. 677)

33.5 How does virtual clinical care provided via telemental health (TMH) compare to
traditional encounters?

A. There is no need to modify psychiatric assessment during a virtual encounter.

B. Clinical care provided by TMH should be consistent with other professional
parameters.
C. Models of care are the same whether medication is prescribed directly by a tele-
psychiatrist or by a referring primary care physician.
D. Additional direction and contact between sessions are not necessary for vir-
tual encounters.

The correct response is option B: Clinical care provided by TMH should be con-
sistent with other professional parameters.

Clinical care provided via TMH should be consistent with professional practice
parameters and guidelines (option B is correct). The American Academy of Child

Telemental Health—Answer Guide | 283

 and Adolescent Psychiatry (AACAP) has published clinical practice parameters on a
number of topics related to psychiatric evaluation and treatment (www.aacap.
org). One AACAP practice parameter specifically addresses telepsychiatry with
children and adolescents (American Academy of Child and Adolescent Psychia-
try 2008). Younger, developmentally impaired, or impulsive youth need a modi-
fied approach. Traditional play sessions may be challenging. The child may be
observed interacting with staff in a structured or free play session (option A is in-
correct). Models of care differ by whether medication is prescribed directly by the
telepsychiatrist, by a collaborating midlevel clinician, or by the referring primary
care physician (option C is incorrect). Regardless of the model used, it is important
to maintain communication with the primary care provider about the treatment.
When prescribing via telepsychiatry, a procedure needs to be in place for provid-
ing prescriptions to patients. An important aspect of medication management is
providing care between TMH sessions. Patients’ families need clear direction and
contact numbers for interim needs such as requesting refills, asking questions,
and reporting adverse effects (option D is incorrect). (Chapter 33, Telemental
Health/Clinical Practice of Telemental Health/Optimizing the Virtual Clinical
Encounter, pp. 679–680)

33.6 Which of the following accurately describes a regulatory issue affecting telemen-
tal health (TMH) services?

A. A telemedicine license eliminates the need for additional licenses to practice

in different states.
B. Virtual encounters are not regulated by Health Insurance Portability and Ac-
countability Act (HIPAA) guidelines.
C. Malpractice insurance needs to cover the telemedicine practice.
D. It is a security violation to collect identifying information about the patient.

The correct response is option C: Malpractice insurance needs to cover the tele-
medicine practice.

It is necessary for malpractice insurance to cover a telemedicine practice (option

C is correct). Efforts toward national telemedicine licensing have so far been un-
successful, and requirements are determined by individual medical boards (op-
tion A is incorrect). Other important factors to consider include the patient’s
privacy and compliance of the videoconferencing (VC) transmission with the HI-
PAA and state law regarding confidentiality of mental health information (option
B is incorrect). When a teleprovider sees a patient for an initial encounter over VC,
it is necessary for the teleprovider to collect identifying information about the pa-
tient to confirm the location of the patient (option D is incorrect). (Chapter 33,
Telemental Health/Establishing a Telemental Health Practice/Regulatory and
Ethical Issues, p. 684)

284 | Telemental Health—Answer Guide

References
American Academy of Child and Adolescent Psychiatry: Practice Parameter for Telepsychiatry
With Children and Adolescents. Washington, DC, American Academy of Child and Adoles-
cent Psychiatry, 2008. Available at: http://www.aacap.org/aacap/Resources_for_Primary_
Care/practice_parameters_and_resource_centers/practice_parameters.aspx. Accessed Sep-
tember 17, 2014.
Myers KM, Sulzbacher S, Melzer SM: Telepsychiatry with children and adolescents: are patients
comparable to those evaluated in usual outpatient care? Telemed J E Health 10(3):278–285,
2004 15650522

Telemental Health—Answer Guide | 285

 C H A P T E R 3 4

Principles of
Psychopharmacology
34.1 What is the general role of parental consent in determining whether a patient
younger than age 18 can undergo a psychiatric assessment?

A. The parents always need to consent to the evaluation.

B. The parents do not need to consent to the evaluation.
C. The parents generally need to consent to the evaluation, although some states
allow underage consent in certain situations.
D. The parents do not need to consent to the evaluation, except in emergency sit-
uations.

The correct response is option C: The parents generally need to consent to the
evaluation, although some states allow underage consent in certain situations.

The primary source of information is usually the patient and his or her family, all
of whom should ideally be included in a comprehensive psychiatric assessment.
If the patient is younger than age 18 years, then the parents or legal guardians
generally need to be present and to consent to the evaluation (option B is incor-
rect). It is important to remain up to date on the state laws that govern individual
practices regarding exceptions to this rule, as some states allow underage consent
in certain situations such as substance abuse treatment, brief counseling, and
emergency situations (option C is correct; options A and D are incorrect). (Chap-
ter 34, Principles of Psychopharmacology/General Principles of Psychophar-
macological Assessment, Diagnosis, and Treatment/Psychiatric Assessment/
Sources of Assessment Information, p. 693)

34.2 When initiation of a psychotropic medication is being considered for a pediatric

patient, within what time frame should the patient ideally have had a physical ex-
amination by his or her primary medical doctor?

A. Within the past 3 months.

B. Within the past 6 months.

287
 C. Within the past 1 year.
D. Within the past 2 years.

The correct response is option C: Within the past 1 year.

Ideally, a pediatric patient will have been seen by his or her primary medical doc-
tor for a physical examination within the year prior to the psychiatric assessment
(option C is correct; options A, B, and D are incorrect). If not, it is often advisable
that the patient be evaluated before psychotropic medication is administered.
(Chapter 34, Principles of Psychopharmacology/General Principles of Psycho-
pharmacological Assessment, Diagnosis, and Treatment/Physical Evaluation/
Physical Examination, p. 697)

34.3 In regard to pharmacokinetics, how do hepatic drug metabolism, renal excretion,

and plasma concentrations of hydrophilic drugs differ between children and
adults?

A. Children may have more rapid elimination of drugs that use hepatic pathways,
more rapid excretion of drugs that use renal pathways, and lower plasma con-
centrations of hydrophilic drugs.
B. Children have less rapid elimination of drugs that use hepatic pathways, less
rapid elimination of drugs that use renal pathways, and higher plasma concen-
trations of hydrophilic drugs.
C. Children have more rapid elimination of drugs that use hepatic pathways, less
rapid elimination of drugs that use renal pathways, and lower plasma concen-
trations of hydrophilic drugs.
D. Children have less rapid elimination of drugs that use hepatic pathways, more
rapid elimination of drugs that use renal pathways, and higher plasma concen-
trations of hydrophilic drugs.

The correct response is option A: Children may have more rapid elimination of
drugs that use hepatic pathways, more rapid excretion of drugs that use renal
pathways, and lower plasma concentrations of hydrophilic drugs.

The primary differences in drug metabolism between children and adults are the
results of two key pharmacokinetic factors: 1) When adjustment is made for body
weight, youth have proportionally more liver tissue. As a result, this population
may have more rapid hepatic drug metabolism, and thus more rapid elimination,
of drugs that use hepatic pathways (Kearns et al. 2003) (options B and D are in-
correct). 2) When adjustment is made for body weight, children may have higher
glomerular filtration rates than adults, possibly resulting in more rapid excretion
of drugs that use renal pathways (Chen et al. 2006) (options B and C are incorrect).
As a result of these pharmacokinetic differences, children may require larger
weight-adjusted doses of psychiatric medications than adults in order to attain
comparable serum drug levels. In addition, these patients may also benefit from
more frequent drug dosing in order to compensate for shorter drug half-lives.
Drugs are also absorbed and distributed differently in children as compared with

288 | Principles of Psychopharmacology—Answer Guide

 adults, requiring further adjustments in dosing. Children have proportionally
more extracellular and total-body water than adults, which may lead to lower
plasma concentrations of hydrophilic drugs (options B and D are incorrect). As a
result, some drugs (e.g., lithium) may require higher weight-based dosing in
youth. (Option A is the correct answer because it is the only option correct for all
three listed characteristics.) (Chapter 34, Principles of Psychopharmacology/
Selecting Psychopharmacological Agents/Drug Metabolism and Disposition/
Pharmacokinetics, p. 701)

34.4 At approximately what age do a child’s pharmacokinetic characteristics begin to

become more like those of an adult?

A. Age 13 years.
B. Age 15 years.
C. Age 18 years.
D. Age 21 years.

The correct response is option B: Age 15 years.

At approximately 15 years of age, a child’s pharmacokinetic characteristics begin

to become more like those of an adult (option B is correct; options A, C, and D are
incorrect). Accordingly, clinicians can generally assume that adult drug doses may
be employed in youth once they reach midadolescence (Jatlow 1987). (Chapter 34,
Principles of Psychopharmacology/Selecting Psychopharmacological Agents/
Drug Metabolism and Disposition/Pharmacokinetics, p. 702)

34.5 Which federal regulatory act first gave pharmaceutical companies greater finan-
cial incentives to voluntarily conduct clinical trials of medications in children and
adolescents?

A. Pediatric Research Equity Act (PREA).

B. Best Pharmaceuticals for Children Act (BPCA).
C. Food and Drug Administration Safety and Innovation Act (FDASIA).
D. Food and Drug Administration Modernization Act (FDAMA).

The correct response is option D: Food and Drug Administration Modernization

Act (FDAMA).

One key means by which the dearth of research in pediatric drugs is being ad-
dressed is through federal legislation on drug studies in children and adolescents
(www.fda.gov). The U.S. Food and Drug Administration Modernization Act of 1997
(FDAMA) gave pharmaceutical companies greater financial incentives to volun-
tarily conduct clinical trials of medications in children and adolescents (option D
is correct). In 2002, the Best Pharmaceuticals for Children Act (BPCA) renewed
the financial incentives previously provided by the FDAMA while authorizing
the National Institutes of Health to fund pediatric studies of older, off-patent
medications (option B is incorrect). One year later, the Pediatric Research Equity

Principles of Psychopharmacology—Answer Guide | 289

 Act (PREA) of 2003 required pharmaceutical companies to begin conducting pe-
diatric studies of drugs in development if those drugs had potential for use in the
young (option A is incorrect). These initiatives were further strengthened in 2012
by the Food and Drug Administration Safety and Innovation Act (FDASIA), which,
in addition to making BPCA and PREA permanent, empowered the FDA to en-
sure that requirements were being met by manufacturers in a timely manner (U.S.
Food and Drug Administration 2012) (option C is incorrect). The passage of these
federal laws has driven an increase in the number of pediatric clinical studies,
resulting in improved data about the efficacy of several medications in children.
(Chapter 34, Principles of Psychopharmacology/Selecting Psychopharmacolog-
ical Agents/Regulatory Considerations, p. 703)

References
Chen N, Aleksa K, Woodland C, et al: Ontogeny of drug elimination by the human kidney. Pediatr
Nephrol 21(2):160–168, 2006 16331517
Jatlow PI: Psychotropic drug disposition during development, in Psychiatric Pharmacosciences of
Children and Adolescents. Edited by Popper C. Washington, DC, American Psychiatric Press,
1987, pp 27–44
Kearns GI, Abdel-Rahman SM, Alander SW, et al: Developmental pharmacology—drug disposi-
tion, action, and therapy in infants and children. N Engl J Med 349(12):1157–1167, 2003
13679531
U.S. Food and Drug Administration: Regulatory Information: Fact Sheet: Pediatric provisions in
the Food and Drug Administration Safety and Innovation Act (FDASIA). Silver Spring,
MD, U.S. Food and Drug Administration, July 9, 2012. Available at: https://www.fda.gov/
RegulatoryInformation/LawsEnforcedbyFDA/SignificantAmendmentstotheFDCAct/
FDASIA/ucm311038.htm. Accessed on May 26, 2014.

290 | Principles of Psychopharmacology—Answer Guide

 C H A P T E R 3 5

Medications Used for

Attention-Deficit/
Hyperactivity Disorder
35.1 When treating attention-deficit/hyperactivity disorder (ADHD), what age group
appears to respond less well to stimulant therapy and may be more treatment re-
fractory?

A. Preschoolers.
B. Latency-age children.
C. Adolescents.
D. Adults.

The correct response is option A: Preschoolers.

An extensive literature has clearly documented the short-term efficacy of methyl-

phenidate treatment, mostly in latency-age white boys (option B is incorrect). Re-
cently, there has been a more robust literature in adults, and a growing literature
exists for the use of stimulants at other ages, for females, and for ethnic minorities
(option D is incorrect). Studies of stimulants in adolescents reported rates of re-
sponse highly consistent with those seen in latency-age children (option C is in-
correct). In contrast, the few studies on preschoolers appear to indicate that young
children respond less well to stimulant therapy, suggesting that in preschoolers
ADHD may be more treatment refractory (option A is correct). (Chapter 35, Medi-
cations Used for Attention-Deficit/Hyperactivity Disorder/Stimulant Treatments/
Stimulant Efficacy, pp. 710–711)

35.2 What is one of the two most commonly reported side effects of stimulant medication?

A. Appetite increase.
B. Sleep disturbances.
C. Mood disturbances.
D. Lethargy.

291
 The correct response is option B: Sleep disturbances.

The most commonly reported side effects associated with the administration of
stimulant medication are appetite suppression (option A is incorrect) and sleep
disturbances (option B is correct). Delay of sleep onset is commonly reported and
usually accompanies late afternoon or early evening administration of stimulant
medications. Less commonly reported are mood disturbances ranging from in-
creased tearfulness and social withdrawal to a full-blown major depression–like
syndrome (option C is incorrect). Other fairly common side effects include head-
aches and abdominal discomfort and, more rarely, increased lethargy and fatigue
(option D is incorrect). (Chapter 35, Medications Used for Attention-Deficit/
Hyperactivity Disorder/Stimulant Treatments/Stimulant Side Effects and Risks,
p. 712)

35.3 Which long-acting stimulant is a prodrug, which is converted in the body to the
active medication after enzymatic hydrolysis?

A. Concerta (methylphenidate).
B. Metadate CD (controlled-delivery methylphenidate).
C. Adderall XR (extended-release mixed salts of levoamphetamine and dextro-
amphetamine).
D. Vyvanse (lisdexamfetamine dimesylate).

The correct response is option D: Vyvanse (lisdexamfetamine dimesylate).

A generation of highly sophisticated, well-developed, safe, and effective long-acting

preparations of stimulant drugs has reached the market and revolutionized the
treatment of attention-deficit/hyperactivity disorder (ADHD). The first of these
medications developed was Concerta, which uses an osmotic pump mechanism to
create an ascending level of methylphenidate in the blood (option A is incorrect).
Metadate CD is a capsule with a mixture of immediate- and delayed-release beads
containing methylphenidate, 30% of which are immediate release and 70% of which
are delayed release (option B is incorrect). Adderall XR is a capsule with a 50:50 ra-
tio of immediate- to delayed-release beads designed to release drug content in a
time course similar to that of Adderall given twice a day (0 and 4 hours) (option C
is incorrect). Lisdexamfetamine dimesylate (LDX) is a novel prodrug in which d-
amphetamine is covalently bound to the amino acid L-lysine. This chemical bond
renders the amphetamine component therapeutically inactive. Following oral ad-
ministration, LDX is converted in the body to the active d-amphetamine after enzy-
matic hydrolysis in a rate-limited manner, at or following absorption. The saturable
rate-limited hydrolysis releases active amphetamine slowly, creating predictable
long-acting delivery of the active drug (d-amphetamine) (option D is correct).
(Chapter 35, Medications Used for Attention-Deficit/Hyperactivity Disorder/
Stimulant Treatments/New-Generation Stimulants/Long-Acting Stimulant For-
mulations, pp. 716–720)

292 | Medications Used for ADHD—Answer Guide

35.4 What is a potential serious side effect of atomoxetine?

A. Decrease in diastolic blood pressure.

B. Abnormal electrocardiographic (ECG) intervals.
C. High abuse potential.
D. Severe liver injury.

The correct response is option D: Severe liver injury.

Atomoxetine was well tolerated in pediatric studies (Spencer et al. 2002). Mild in-
creases in diastolic blood pressure and heart rate were noted in the atomoxetine
treatment group (option A is incorrect), with no significant differences between
atomoxetine and placebo in laboratory parameters and ECG intervals (option B is
incorrect). Rare cases of severe liver injury have been reported in a denominator of
greater than 3 million patients who have taken atomoxetine since approval (op-
tion D is correct). While cases were rare and several of the patients recovered, se-
vere drug-related liver injury might progress to acute liver failure resulting in death
or the need for liver transplant. Atomoxetine has been shown to have low abuse
potential (Heil et al. 2002) (option C is incorrect). (Chapter 35, Medications Used
for Attention-Deficit/Hyperactivity Disorder/Nonstimulants/Specific Norepi-
nephrine Reuptake Inhibitors/Atomoxetine Side Effects and Risks, pp. 722–723)

35.5 Which of the following nonstimulant medications has U.S. Food and Drug Admin-
istration (FDA) approval for the treatment of attention-deficit/hyperactivity disor-
der (ADHD)?

A. Immediate-release clonidine.
B. Extended-release guanfacine.
C. Bupropion.
D. Tricyclic antidepressants.

The correct response is option B: Extended-release guanfacine.

Immediate-release clonidine does not have an FDA-approved indication for the

treatment of ADHD. However, immediate-release clonidine has been widely used in
children with ADHD, despite a paucity of studies (option A is incorrect). There were
two large 8- to 9-week randomized, double-blind, multicenter studies of extended-
release guanfacine (GXR) in children ages 6–17 years diagnosed with ADHD (Bie-
derman et al. 2008). Efficacy for ADHD was substantial and proportionate to
weight-corrected dose. The results of this study led to the FDA approval of GXR
in doses of 1, 2, 3, and 4 mg (option B is correct). Of nonstimulants, noradrenergic
and dopaminergic compounds, including monoamine oxidase inhibitors, second-
ary amine tricyclic antidepressants, and bupropion, have been found to be superior
to placebo in controlled clinical trials. However, none of them are FDA approved
for treatment of ADHD (options C and D are incorrect). (Chapter 35, Medications
Used for Attention-Deficit/Hyperactivity Disorder/Noradrenergic Modulators:
Clonidine and Guanfacine, pp. 724–725; Antidepressants, p. 727)

Medications Used for ADHD—Answer Guide | 293

35.6 Which of the following is true regarding nonstimulant pharmacotherapy for at-
tention-deficit/hyperactivity disorder (ADHD)?

A. Guanfacine extended release (GXR) should not be used adjunctively with

stimulants.
B. Bupropion has an indirect mixed antagonist effect on dopamine and norepi-
nephrine.
C. Selective serotonin reuptake inhibitors (SSRIs) are useful in treating symptoms
of ADHD.
D. Modafinil has the potential side effect of causing serious Stevens-Johnson–like
rashes.

The correct response is option D: Modafinil has the potential side effect of caus-
ing serious Stevens-Johnson–like rashes.

Across multiple studies, the safety and tolerability profile of GXR administered
adjunctively to a psychostimulant has been consistent with the known profiles of
each medication. The results of this study led to the U.S. Food and Drug Admin-
istration (FDA) approval of use of combined GXR plus stimulant treatment (op-
tion A is incorrect). Although its specific site and mechanism of action remains
unknown, bupropion seems to have an indirect mixed agonist effect on dopamine
and norepinephrine neurotransmission (option B is incorrect). At present, expert
opinion does not support the usefulness of SSRIs in the treatment of core ADHD
symptoms (National Institute of Mental Health 1996) (option C is incorrect).
While there is evidence of the effectiveness of modafinil in ADHD, the drug was not
FDA approved for ADHD because of concerns about a few potentially serious Ste-
vens-Johnson–like rashes in these trials (option D is correct). When used off-label for
ADHD in children, the risk-benefit evaluation should take into account the possi-
bility of a rash of this type. (Chapter 35, Medications Used for Attention-Deficit/
Hyperactivity Disorder/Noradrenergic Modulators: Clonidine and Guanfacine,
p. 727; Antidepressants, pp. 727–729; Other Compounds, p. 729)

References
Biederman J, Melmed RD, Patel A, et al: A randomized, double-blind, placebo-controlled study of
guanfacine extended release in children and adolescents with attention-deficit/hyperactivity
disorder. Pediatrics 121(1):e73–e84, 2008 18166547
Heil SH, Holmes HW, Bickel WK, et al: Comparison of the subjective, physiological, and psycho-
motor effects of atomoxetine and methylphenidate in light drug users. Drug Alcohol Depend
67(2):149–156, 2002 12095664
National Institute of Mental Health: Alternative Pharmacology of ADHD. Bethesda, MD, National
Institute of Mental Health, 1996
Spencer T, Heiligenstein JH, Biederman J, et al: Results from 2 proof-of-concept, placebo-controlled
studies of atomoxetine in children with attention-deficit/hyperactivity disorder. J Clin Psy-
chiatry 63(12):1140–1147, 2002 12523874

294 | Medications Used for ADHD—Answer Guide

 C H A P T E R 3 6

Antidepressants
36.1 Increased rates of suicidality reported in children and adolescents treated with
antidepressants relative to placebo appear to extend to what age?

A. Age 18 years.
B. Age 21 years.
C. Age 24 years.
D. Age 28 years.

The correct response is option C: Age 24 years.

It appears that increased rates of suicidality reported in children and adolescents

treated with antidepressants relative to placebo extend only to age 24 (option C is
correct; options A, B, and D are incorrect). (Chapter 36, Antidepressants/Safety,
p. 739)

36.2 A 16-year-old boy with recurrent major depressive disorder and a seizure disor-
der has not responded to treatment with an adequate trial of fluoxetine. His de-
pression did not improve with a prior adequate trial of escitalopram. Which of the
following would be the next appropriate psychopharmacological treatment?

A. Tranylcypromine.
B. Nortriptyline.
C. Venlafaxine.
D. Bupropion.

The correct response is option C: Venlafaxine.

Monoamine oxidase inhibitors (MAOIs; e.g., phenelzine, isocarboxazid, tranylcy-

promine, selegiline, moclobemide, and brofaromine) are seldom used in children
and adolescents because of requisite dietary restrictions, multiple side effects, and
multiple dangerous (possibly fatal) drug-drug interactions (option A is incorrect).
The use of tricyclic antidepressants (TCAs; such as amitriptyline, clomipramine,
imipramine, desipramine, and nortriptyline) in children has fallen out of favor
with the advent of newer antidepressants and case reports of sudden death in
children taking TCAs. Meta-analyses of TCAs have shown no significant differences

295
 from placebo in depressed youth (Maneeton and Srisurapanont 2000). The unfa-
vorable side-effect profile of TCAs and limited evidence of efficacy make it diffi-
cult to determine the role of TCAs in pediatric psychopharmacology (option B is
incorrect). On the basis of current guidelines from the Texas Children’s Medica-
tion Algorithm Project for childhood major depressive disorder, bupropion, ven-
lafaxine, mirtazapine, and duloxetine are stage 3 interventions. This means that
depressed children should have failed at least two adequate trials of selective
serotonin reuptake inhibitors (SSRIs) prior to treatment with these novel agents
(option C is correct). Bupropion is contraindicated in patients with epilepsy or
eating disorders or other individuals at risk for seizures (option D is incorrect).
(Chapter 36, Antidepressants/Atypical Antidepressants, pp. 753, 755; Tricyclic
Antidepressants, p. 761; Monoamine Oxidase Inhibitors, p. 762)

36.3 A 6-year-old girl presents with obsessions of contamination and compulsive hand-
washing to relieve her fears. Which medication is U.S. Food and Drug Adminis-
tration (FDA) approved for use in this girl?

A. Fluvoxamine.
B. Sertraline.
C. Fluoxetine.
D. Citalopram.

The correct response is option B: Sertraline.

Fluoxetine, fluvoxamine, and sertraline all are FDA approved to treat pediatric
obsessive-compulsive disorder (OCD) (Table 36–1). Fluvoxamine is approved for
treatment of OCD in patients 8 years and older (option A is incorrect). Sertraline
is approved for use in patients with OCD who are ages 6 years and older (option
B is correct). Fluoxetine is approved for use in pediatric OCD in children 7 years
and older (option C is incorrect). Citalopram is not approved for use in pediatric
OCD (option D is incorrect). (Chapter 36, Antidepressants/Table 36–2, p. 742)

36.4 Of the most commonly used alternative or complementary remedies for depres-
sive and anxiety disorders—St. John’s wort, omega-3 fatty acid, and S-adenosyl-
methionine—which has some limited randomized controlled trial (RCT) evidence in-
dicating potential benefit of its use in pediatric depressive or anxiety disorders?

A. Omega-3 fish oil, when used in children with depression.

B. St. John’s wort, when used in children with anxiety disorders.
C. S-adenosyl-methionine, when used in children with depression.
D. S-adenosyl-methionine, when used in children with anxiety disorders.

The correct response is option A: Omega-3 fish oil, when used in children with
depression.

The use of alternative or complementary medicine is popular among pediatric pa-

tients despite little empirical evidence. One small controlled study with pediatric

296 | Antidepressants—Answer Guide

TABLE 36–1. U.S. Food and Drug Administration (FDA) indications for selective
serotonin reuptake inhibitors
Medication FDA-approved indication Indication age range

Citalopram (Celexa) Depression Adults

Escitalopram (Lexapro) Depression 12 years to adult
GAD Adults
Fluoxetine (Prozac) Bulimia Adults
Depression 8 years to adult
OCD 7 years to adult
PD Adults
Depressive episodes (bipolar disorder) Adults
Fluvoxamine (Luvox) OCD 8 years to adult
Paroxetine (Paxil) Depression Adults
GAD Adults
OCD Adults
PD Adults
PMDD Adults
PTSD Adults
SOC Adults
Sertraline (Zoloft) Depression Adults
OCD 6 years to adult
PD Adults
PMDD Adults
PTSD Adults
SOC Adults
Note. GAD=generalized anxiety disorder; OCD=obsessive-compulsive disorder; PD=panic disorder;
PMDD=premenstrual dysphoric disorder; PTSD=posttraumatic stress disorder; SOC=social anxiety dis-
order.

depression has been done with omega-3 fish oil. Nemets et al. (2006) reported data
on 20 Israeli children with depression randomly assigned to receive omega-3 fish
oil or placebo for 16 weeks. Of children who received a 1,000-mg daily dose of
omega-3 fish oil, 70% responded versus 0% in the placebo group (option A is cor-
rect). The omega-3 fish oil was well tolerated, and no significant side effects were
reported. No studies of omega-3 fish oil have been reported in pediatric anxiety
disorder. In open studies of St. John’s wort, a daily dose between 300 mg and 1,800
mg was well tolerated by children. No RCTs of St. John’s wort in pediatric depres-
sion or anxiety disorders have been published (option B is incorrect). No pediatric
studies in pediatric depressive or anxiety disorders have been done for S-adenosyl-
methionine (options C and D are incorrect). (Chapter 36, Antidepressants/Alter-
native Antidepressant Treatments, p. 762)

Antidepressants—Answer Guide | 297

36.5 Which antidepressant has U.S. Food and Drug Administration (FDA) approval
for treatment of depression in both children and adolescents?

A. Citalopram.
B. Escitalopram.
C. Venlafaxine.
D. Fluoxetine.

The correct response is option D: Fluoxetine.

Tables in this chapter detail the various FDA approvals for medications. Citalo-
pram has an FDA-approved indication for treatment of depression in adults but
not in children or adolescents (option A is incorrect); escitalopram has an FDA-
approved indication for treatment of depression in adolescents but not in children
(option B is incorrect); and fluoxetine is the only antidepressant with an FDA-
approved indication for treatment of depression in both children and adolescents
(option D is correct). Venlafaxine has an FDA-approved indication for treatment
of depression in adults but not in either children or adolescents (Table 36–2) (option
C is incorrect). (Chapter 36, Antidepressants/Table 36–2, p. 742; Table 36–4, p. 746)

TABLE 36–2. U.S. Food and Drug Administration (FDA) indications for atypical
antidepressants
Medication Drug class FDA-approved indication (adults only)

Bupropion (Wellbutrin) NDRI Depression

Desvenlafaxine (Pristiq) SNRI Depression, vasomotor symptoms associated
with menopause
Duloxetine (Cymbalta) SSNRI Depression, GAD, diabetic peripheral
neuropathic pain, fibromyalgia, chronic
musculoskeletal pain
Levomilnacipran (Fetzima) SSNRI Depression
Mirtazapine (Remeron) NaSSA Depression
Trazodone (Desyrel) SARI Depression
Venlafaxine (Effexor) SSNRI Depression, GAD
Vilazodone (Viibryd) SSRI and partial Depression
5-HT1A agonist
Vortioxetine (Brintellix) SMS Depression
Note. GAD=generalized anxiety disorder; NaSSA=noradrenergic and specific serotonergic antidepressant;
NDRI=norepinephrine-dopamine reuptake inhibitor; SARI=serotonin agonist and serotonin reuptake inhibi-
tor; SSNRI=selective serotonin-norepinephrine reuptake inhibitor; SMS=serotonin modulator and stimulator.

References
Maneeton N, Srisurapanont M: Tricyclic antidepressants for depressive disorders in children and
adolescents: a meta-analysis of randomized-controlled trials. J Med Assoc Thai 83(11):1367–
1374, 2000 11215868
Nemets H, Nemets B, Apter A, et al: Omega-3 treatment of childhood depression: a controlled,
double-blind pilot study. Am J Psychiatry 163(6):1098–1100, 2006 16741212

298 | Antidepressants—Answer Guide

 C H A P T E R 3 7

Mood Stabilizers
37.1 Which surveillance study should be performed at least every 6 months in children
and adolescents taking lithium?

A. Electrocardiogram (ECG).
B. Calcium level.
C. Thyroid function tests.
D. High-level ultrasound.

The correct response is option C: Thyroid function tests.

Lithium may occasionally affect cardiac conduction, causing first-degree atrio-

ventricular block, irregular sinus rhythms, and increased premature ventricular
contractions. It is recommended that a baseline ECG be obtained, followed by an-
other ECG once a therapeutic level has been reached (option A is incorrect). Close
monitoring of thyroid function in children and adolescents taking lithium is rec-
ommended, as some may require supplemental thyroid hormone. Thyroid func-
tion should be tested at baseline, during the first 6 months of treatment, and then
every 6 months or when clinically indicated (option C is correct). Chronic treat-
ment with lithium can cause hyperparathyroidism; therefore, serum calcium lev-
els should be checked at baseline and then once a year (option B is incorrect).
Adequate birth control measures must be followed in adolescent females taking
lithium, as lithium has been associated with an increased rate of cardiac abnor-
malities following fetal exposure. Although more recent prospective epidemio-
logical studies have indicated bias in the initial reports and a lower rate of cardiac
abnormalities that may not be elevated compared with control pregnancies, po-
tential benefits for lithium treatment in those young women with severe illness
must be balanced with a discussion of potential risk and appropriate fetal moni-
toring by high-level ultrasound (option D is incorrect). (Chapter 37, Mood Stabi-
lizers/Disorders in Which Lithium May Be Useful/Side Effects, pp. 773–774)

37.2 Which mood stabilizer is the only one approved by the U.S. Food and Drug Ad-
ministration (FDA) for the treatment of manic episodes of bipolar illness in pa-
tients ages 12 years and older?

299
 A. Valproate.
B. Lithium carbonate.
C. Long-acting form of carbamazepine.
D. Lamotrigine.

The correct response is option B: Lithium carbonate.

Lithium carbonate is the best-studied classic mood stabilizer in children and ad-
olescents and is the only one approved by the FDA for the treatment of “manic
episodes of manic-depressive illness” in patients ages 12 years and older (option B
is correct). Valproate is currently approved by the FDA for the treatment of adults
with partial complex seizures, migraines, or manic episodes of bipolar illness (op-
tion A is incorrect). A long-acting form of carbamazepine has an FDA-approved
indication for the treatment of acute manic or mixed episodes in adults with bipo-
lar I disorders (option C is incorrect). Lamotrigine is an antiseizure agent indicated as
adjunct therapy for partial seizures, the generalized seizures of Lennox-Gastaut syn-
drome, and primary generalized tonic-clonic seizures in adults and children >2
years of age. The FDA has approved lamotrigine for the maintenance treatment
of bipolar I disorder in adults to delay the time to reoccurrence of mood episodes in
patients already treated for acute mood episodes with standard therapy (option D
is incorrect). (Chapter 37, Mood Stabilizers, pp. 769–780)

37.3 A 16-year-old girl develops weight gain, acne, hirsutism, and irregular menstru-
ation after 6 months of medication treatment for bipolar disorder. She is evaluated
by an endocrinologist who diagnoses polycystic ovarian syndrome (PCOS).
Which mood stabilizer is most commonly associated with this condition?

A. Lithium.
B. Valproate.
C. Carbamazepine.
D. Lamotrigine.

The correct response is option B: Valproate.

There is an association between valproate and PCOS. Common signs and symp-
toms of PCOS include irregular or absent menstruation, lack of ovulation, weight
gain, adverse metabolic changes including hyperinsulinemia, hirsutism, and/or
acne (option B is correct). Common side effects of lithium in children and adoles-
cents include nausea, diarrhea, abdominal distress, sedation, tremor, polyuria,
weight gain, enuresis, and acne (option A is incorrect). Common side effects of
carbamazepine in children and adolescents include headache, sedation, ataxia,
dizziness, blurred vision, nausea, and vomiting. Uncommon side effects include
aplastic anemia, agranulocytosis, hyponatremia, toxic epidermal necrolysis, and
Stevens-Johnson syndrome (option C is incorrect). The most common side effects
of lamotrigine are dizziness, tremor, somnolence, nausea, asthenia, and headache.
Blurred vision and cognitive difficulties, including word-finding problems, can oc-

300 | Mood Stabilizers—Answer Guide

 cur and may respond to lowering the dose. Cases of lupus, leukopenia, agranulo-
cytosis, hepatic failure, and multiorgan failure associated with lamotrigine treat-
ment have been reported (Sabers and Gram 2000). Benign rashes develop in 12%
of adult patients, typically within the first 8 weeks of lamotrigine therapy (Calabrese
et al. 2002). Rarely, severe cutaneous reactions such as Stevens-Johnson syndrome
and toxic epidermal necrolysis have been described. The risk of developing a se-
rious rash is approximately three times greater in children and adolescents younger
than age 16 years compared with adults (option D is incorrect). (Chapter 37, Mood
Stabilizers, pp. 772–781)

37.4 The addition of carbamazepine may result in increased levels of which of the fol-
lowing medications?

A. Oral contraceptives.
B. Phenobarbital.
C. Lithium.
D. Valproate.

The correct response is option C: Lithium.

Because of its stimulation of the hepatic P450 isoenzyme system, carbamazepine

has many clinically significant drug interactions. Carbamazepine decreases lith-
ium clearance, increasing the risk of lithium toxicity (option C is correct). Carbamaz-
epine may decrease the levels of the following medications: oral contraceptives,
clonazepam, glucocorticoids, phenobarbital, primidone, phenytoin, tricyclics,
valproate, and lamotrigine (options A, B, and D are incorrect). Carbamazepine
can also decrease the serum levels of many of the atypical antipsychotics, leading
to symptomatic relapses in some patients. (Chapter 37, Mood Stabilizers/Carba-
mazepine/Drug Interactions pp. 779–780)

37.5 What is the frequency of serious rash (requiring hospitalization and discontinuation
of treatment) associated with lamotrigine in children under the age of 16 years?

A. 1 per 100.
B. 3 per 1,000.
C. 1–6 per 10,000.
D. 10 per 10,000.

The correct response is option A: 1 per 100.

The frequency of serious rash associated with lamotrigine (rashes requiring hos-
pitalization and discontinuation of treatment), including Stevens-Johnson syn-
drome, is approximately 1/100 (1%) in children ages younger than 16 years and
3/1,000 (0.3%) in adults (GlaxoSmithKline 2001) (option A is correct; options B,
C, and D are incorrect). (Chapter 37, Mood Stabilizers/Lamotrigine/Side Effects,
p. 781)

Mood Stabilizers—Answer Guide | 301

References
Calabrese JR, Sullivan JR, Bowden CL, et al: Rash in multicenter trials of lamotrigine in mood dis-
orders: clinical relevance and management. J Clin Psychiatry 63(11):1012–1019, 2002 12444815
GlaxoSmithKline: Lamictal (lamotrigine) product information, in Physicians Desk Reference, 56th
Edition. Research Triangle Park, NC, Thomson Healthcare, 2001. Available at: http://
www.pdr.net/full-prescribing-information/lamictalxr?druglabelid=207. Accessed March 29,
2015
Sabers A, Gram L: Newer anticonvulsants: comparative review of drug interactions and adverse
effects. Drugs 60(1):23–33, 2000 10929928

302 | Mood Stabilizers—Answer Guide

 C H A P T E R 3 8

Antipsychotic
Medications
38.1 Which of the following antipsychotic side effects is most common among children
and adolescents?

A. Weight gain.
B. Diabetes or tardive dyskinesia.
C. Abnormal liver enzymes.
D. Neutropenia.

The correct response is option A: Weight gain.

Children and adolescents seem to be more sensitive to most antipsychotic adverse

effects, including sedation, extrapyramidal symptoms (except for akathisia),
withdrawal dyskinesia, prolactin abnormalities, weight gain, and metabolic ab-
normalities (Correll et al. 2006) (option A is correct). Adverse effects that require
a longer time to develop (e.g., diabetes mellitus) and that are related to greater
medication dose and lifetime exposure (e.g., tardive dyskinesia [TD]) are less
prevalent in youth than in adults (option B is incorrect). Abnormal liver enzymes
have been reported with pediatric antipsychotic use (Kumra et al. 1997; Sikich et
al. 2004, 2008), and liver enzyme testing to check for potential signs of fatty liver
infiltration should be considered in patients who 1) have abdominal/gastrointes-
tinal symptoms, 2) gain ≥7% of their baseline body weight over 3 months, or 3) have
≥0.5 BMI z scores when treated for >3 months. In patients with aspartate transam-
inase, alanine aminotransferase, or γ-glutamyl transferase levels three times the
norm and without other medical causes, discontinuation of the antipsychotic or
of possibly responsible co-medications should be considered (option C is incor-
rect). With the exception of clozapine, the antipsychotic-associated decrease in
white blood cell counts (i.e., neutropenia) is generally not clinically significant,
and therefore routine blood draws are not required (option D is incorrect). (Chap-
ter 38, Antipsychotic Medications/Adverse Effects, pp. 824, 829; Adverse Effect
Assessment and Monitoring, p. 834)

303
38.2 Which one of the following is a U.S. Food and Drug Administration (FDA)–
approved indication for antipsychotic use in youth?

A. Schizotypal personality disorder.

B. Oppositional defiant disorder.
C. Irritability associated with autism spectrum disorder.
D. Obsessive-compulsive disorder.

The correct response is option C: Irritability associated with autism spectrum

disorder.

Various antipsychotics have FDA-approved indications for use in youth with

schizophrenia, bipolar mania, and irritability associated with autism spectrum
and tic disorders (option C is correct). Oppositional defiant disorder is not an FDA-
approved indication for antipsychotic use in youth (option B is incorrect); al-
though efficacy data exist for risperidone in disruptive behavior disorders, use of
antipsychotics for aggression or impulsivity is recommended only after treat-
ments for underlying disorders and nonpharmacological interventions have been
exhausted. Obsessive-compulsive disorder and schizotypal personality disorder
are not FDA-approved indications for antipsychotic use in youth (options A and
D are incorrect). (Chapter 38, Antipsychotic Medications, p. 839)

38.3 The central pharmacodynamic feature of all antipsychotics is their ability to do

which of the following?

A. Block the dopamine D1 receptor.

B. Block the dopamine D2 receptor.
C. Bind to serotonin receptors.
D. Bind to histamine receptors.

The correct response is option B: Block the dopamine D2 receptor.

The central feature of all antipsychotics is their ability to block the dopamine D2
(not D1) receptor (option B is correct; option A is incorrect). This activity seems to
be associated with the antipsychotic, antimanic, anti-tic, and antiaggressive ef-
fects of antipsychotic medications. Most antipsychotic drugs also bind to sero-
tonin and α-adrenergic, histaminic, or muscarinic receptors, which can in part
predict the therapeutic and adverse effects during therapy with a particular drug
(Correll et al. 2010) (options C and D are incorrect). Antipsychotics that bind more
tightly to receptors other than D2 receptors contain these effects in addition to the
antidopaminergic efficacy. In the case of antipsychotics with relatively weak do-
pamine binding (e.g., clozapine, quetiapine), non-antidopaminergic effects can
predominate at low doses. The tighter binding at nondopaminergic receptors can
be beneficial, as in the tighter binding of second-generation antipsychotics to se-
rotonin 5-HT2 receptors, which seems to be associated with less propensity for ex-
trapyramidal symptoms. Conversely, the stronger binding to non-dopaminergic
receptors can also lead to lasting adverse effects of an antihistaminergic or anti-

304 | Antipsychotic Medications—Answer Guide

 cholinergic nature. (Chapter 38, Antipsychotic Medications/Pharmacology/
Pharmacodynamic Considerations, p. 802)

38.4 What metabolic feature of antipsychotics can be associated with sexual side effects?

A. QTc prolongation.
B. Hyperprolactinemia.
C. Sedation.
D. Liver enzyme abnormalities.

The correct response is option B: Hyperprolactinemia.

Both first- and second-generation antipsychotics can elevate prolactin levels. Hy-
perprolactinemia can result in sexual side effects (option B is correct), although
prolactin levels are not tightly correlated with symptoms including amenorrhea
or oligomenorrhea, erectile dysfunction, decreased libido, hirsutism, and breast
symptoms such as enlargement, engorgement, pain, or galactorrhea (Correll 2008).
Data also suggest that hyperprolactinemia is dose dependent, reduces over time,
and resolves after antipsychotic discontinuation. The relative potency of antipsy-
chotic drugs in increasing prolactin levels is higher in adolescents than in adults
but follows roughly the same pattern: paliperidone ≥ risperidone > haloperidol >
olanzapine > ziprasidone > quetiapine ≥ clozapine > aripiprazole (Correll 2008).
To date, adequate long-term data are lacking to determine if hyperprolactinemia
at levels found during antipsychotic therapy alters bone density, sexual matura-
tion, or the risk for benign prolactinomas. Antipsychotics can differentially pro-
long the heart rate–corrected QT interval of the electrocardiogram, which may be
associated with torsades de pointes, a potentially fatal arrhythmia (option A is in-
correct). Sedation is a frequent and often impairing antipsychotic side effect that
usually is dose dependent, although tolerance may develop (option C is incorrect).
Abnormal liver enzymes have been reported with pediatric antipsychotic use
(Kumra et al. 1997; Sikich et al. 2004, 2008). In two randomized controlled trials of
olanzapine (Kryzhanovskaya et al. 2009; Tohen et al. 2007), significantly more pa-
tients had abnormal liver function tests of greater than three times the norm than
patients on placebo (option D is incorrect). (Chapter 38, Antipsychotic Medica-
tions/Adverse Effects, pp. 828–829)

38.5 Which of the following is a tertiary prevention strategy?

A. Choosing an agent with the lowest likelihood of adverse effects on body com-
position and metabolic status.
B. Intensified weight reduction interventions.
C. Intensification of healthy lifestyle instructions.
D. Consideration of switching to a lower-risk agent.

The correct response is option B: Intensified weight reduction interventions.

Antipsychotic Medications—Answer Guide | 305

 Intensified weight reduction interventions is an example of a tertiary prevention
strategy (option B is correct). Choosing an agent with the lowest likelihood of ad-
verse effects on body composition and metabolic status is a primary prevention
strategy (option A is incorrect). Intensification of healthy lifestyle instructions
and consideration of switching to a lower-risk agent are both secondary preven-
tion strategies (options C and D are incorrect). (Chapter 38, Antipsychotic Med-
ications/Managing Adverse Effects, p. 837)

References
Correll CU: Antipsychotic use in children and adolescents: minimizing adverse effects to maxi-
mize outcomes. J Am Acad Child Adolesc Psychiatry 47(1):9–20, 2008 18174821
Correll CU, Penzner JB, Parikh UH, et al: Recognizing and monitoring adverse events of second-
generation antipsychotics in children and adolescents. J Child Adolesc Psychiatr Clin N Am
15(1):177–206, 2006 16321730
Correll CU, Schenk EM, DelBello MP: Antipsychotic and mood stabilizer efficacy and tolerability
in adult and pediatric patients with bipolar I mania: a comparative analysis of acute, random-
ized, placebo-controlled trials. Bipolar Disord 12(2):116–141, 2010 20402706
Kryzhanovskaya L, Schulz SC, McDougle C, et al: Olanzapine versus placebo in adolescents with
schizophrenia: a 6-week, randomized, double-blind, placebo-controlled trial. J Am Acad
Child Adolesc Psychiatry 48(1):60–70, 2009 19057413
Kumra S, Herion D, Jacobsen LK, et al: Case study: risperidone-induced hepatotoxicity in pediat-
ric patients. J Am Acad Child Adolesc Psychiatry 36(5):701–705, 1997 9136506
Sikich L, Hamer RM, Bashford RA, et al: A pilot study of risperidone, olanzapine, and haloperidol
in psychotic youth: a double-blind, randomized, 8-week trial. Neuropsychopharmacology
29(1):133–145, 2004 14583740
Sikich L, Frazier JA, McClellan J, et al: Double-blind comparison of first- and second-generation
antipsychotics in early onset schizophrenia and schizoaffective disorder: findings from the
treatment of early onset schizophrenia spectrum disorders (TEOSS) study. Am J Psychiatry
165(11):1420–1431, 2008 18794207
Tohen M, Kryzhanovskaya L, Carlson G, et al: Olanzapine versus placebo in the treatment of ad-
olescents with bipolar mania. Am J Psychiatry 164(10):1547–1556, 2007 17898346

306 | Antipsychotic Medications—Answer Guide

 C H A P T E R 3 9

Individual Psychotherapy
39.1 Which psychodynamic construct is defined as the psychological space (and energies)
occupied by ways of coping, defending against the drives, thinking things through,
and dealing with loved ones and the world—both conscious and unconscious?

A. Id.
B. Ego.
C. Superego.
D. Ego ideal.

The correct response is option B: Ego.

The id is the psychological space (and energies) occupied by primitive, raw sexual
and aggressive drives, most of which are unconscious (option A is incorrect). The ego
is the psychological space (and energies) occupied by ways of coping, defending
against the drives, thinking things through, and dealing with loved ones and the
world—both conscious and unconscious (option B is correct). The superego is made
up of the particular ways “conscience,” ethics, ideals, morals, and role models oper-
ate in mentality—both conscious and unconscious (option C is incorrect). The ego
ideal is who and what a person wishes to become, or a person’s better self (option D
is incorrect). (Chapter 39, Individual Psychotherapy/Table 39–1, pp. 850–851)

39.2 If a therapist working with a child is taking a supportive approach in the psycho-
therapy treatment, the therapist might employ which of the following techniques?

A. Interpretation.
B. Clarification.
C. Modeling.
D. Maintenance of a neutral stance.

The correct response is option C: Modeling.

As defined in Table 39–1, uncovering psychotherapy is a type of treatment primarily

using exploration of defenses, conscience, secret wishes, and transference in order
to resolve internal unconscious conflict, whereas supportive psychotherapy is a type
of treatment using the real relationship with the therapist, education, suggestions,

307
TABLE 39–1. Glossary of terms
Term or phrase
(in order of presentation) Definition

Psychodynamic psychotherapy Psychological treatment of a child, based on such Freudian

principles as internal conflict, the unconscious, repetition
compulsion, and transference
Uncovering psychotherapy A type of treatment primarily using exploration of defenses,
conscience, secret wishes, and transference in order to
resolve internal unconscious conflict
Supportive psychotherapy A type of treatment using the real relationship with the
therapist, education, suggestions, and reinforcements to
help a patient cope with the external world
Displacement Defense mechanism in which the object of a conflict is
moved over to someone else, an animal, or even a thing or
idea
Oedipal The conscious or unconscious wish to marry the parent of
the opposite sex and rid the self of the same-sex parent
Id The psychological space (and energies) occupied by
primitive, raw sexual and aggressive drives, most of which
are unconscious
Ego The psychological space (and energies) occupied by ways of
coping, defending against the drives, thinking things
through, and dealing with loved ones and the world—both
conscious and unconscious
Interpretation The therapist’s bringing together of ideas about the patient’s
defenses, wishes, conscience, and/or dealings with the
world that makes unconscious mechanisms visible and
therefore workable
Superego The particular ways “conscience,” ethics, ideals, morals, and
role models operate in mentality—both conscious and
unconscious
Clarification The therapist’s putting new words to something the patient
already knows in a different way
Transference The patient’s particular defensive displacement toward the
therapist, based on old attitudes and feelings about
important others in the patient’s life
Education Teaching something to the patient
Suggestion Guiding the patient to a conclusion the patient eventually
makes, which can be unconscious on the patient’s part or
entirely conscious
Modeling Showing the patient—in the therapist’s actions—how to act
or be
Reinforcement Responding to the patient’s actions or story positively or
negatively and thereby demonstrating how the therapist
wants the patient to behave
Real therapist Either being actual or telling the patient who the actual
person treating him or her is

308 | Individual Psychotherapy—Answer Guide

TABLE 39–1. Glossary of terms (continued)
Term or phrase
(in order of presentation) Definition

Mentalization The ability to reflect on and hold in mind the mental states
(feelings, thoughts, beliefs) of oneself and others
Diagnosis The synthesis of history, observation, and tests, leading to
the indication of a certain medical condition that is treated
in a prescribed way
Formulation The working psychological explanation for a patient’s
feelings, behavior, and thinking
Abreaction The expression of emotion relating to a problem,
particularly psychic trauma
Context The perspective and understanding, particularly of a
psychic trauma, in terms of history, geography, science,
peer group, criminology, and so forth
Correction The imaginary or real solution to a traumatic event, even if
it is an old one and/or virtually unsolvable
Denial in fantasy Defense mechanism in which a painful reality is overlooked
or forgotten by constructing a situation in one’s
imagination that negates or obscures the reality
Family therapy Treating a dysfunctional unit (siblings, parent(s), step- or
half-siblings, originally targeted child, other key figures)
Filial therapy Treating a child through the parent (who takes the doctor’s
ideas home and tries them out on the young person)
Collaborative therapy Treating a child while having one or more other clinicians
treat the parent(s) or sibling(s)
Countertransference The clinician’s unreasonable, personally based responses to
a patient
Repetition compulsion The need to refeel, retell, redream, or reenact (in conflicted
or traumatized people)
Reenactment Repetitive behavior (often related to past trauma) that
replays a thought, a fear, or an original behavior from the
event(s)
Ego ideal Who and what a person wishes to become, or a person’s
better self

and reinforcements to help a patient cope with the external world. To uncover
with an adult, the therapist needs interpretation and clarification (options A and
B are incorrect). The therapist also needs to maintain a neutral and relatively pas-
sive stance (option D is incorrect). This rather distant approach is intended to en-
courage transference, the displacement of old attitudes, especially about the
patient’s family of origin, to the therapist. To support a child, on the other hand,
the therapist is taught to employ more education, suggestion, modeling, and pos-
itive or negative reinforcement (option C is correct). The psychotherapist is also
encouraged to be real with the patient in order to avoid potentially dangerous
transference in seriously disordered children and to help very disturbed young peo-
ple learn how to act in society. (Chapter 39, Individual Psychotherapy, p. 852)

Individual Psychotherapy—Answer Guide | 309

39.3 What phenomenon is regarded by some as less important in the treatment of
young children than in treatment of adults because children are still primarily in-
volved in their families of origin?

A. Correction.
B. Abreaction.
C. Repetition compulsion.
D. Transference.

The correct response is option D: Transference.

Transference is the patient’s particular defensive displacement toward the thera-

pist, based on old attitudes and feelings about important others in the patient’s life
(see Table 39–1). Over the years, child psychotherapists have recognized that trans-
ference is not as important a phenomenon in the treatment of young children as it
is in adults. This happens because children are still primarily involved in their
families of origin and therefore do not consistently displace these feelings to their
treating physician or counselor (option D is correct). The concepts of correction (the
imaginary or real solution to a traumatic event, even if it is an old one and/or virtu-
ally unsolvable), abreaction (the expression of emotion relating to a problem, particu-
larly psychic trauma), and repetition compulsion (the need to refeel, retell, redream, or
reenact [in conflicted or traumatized people]) do not relate directly to families of
origin (options A, B, and C are incorrect). (Chapter 39, Individual Psychotherapy,
p. 852; Table 39–1, pp. 850–851)

39.4 A therapist who is treating a child while one or more other clinicians treat the par-
ent(s) or sibling(s) is engaging in what form of treatment?

A. Supportive psychotherapy.
B. Family therapy.
C. Collaborative therapy.
D. Filial therapy.

The correct response is option C: Collaborative therapy.

Supportive psychotherapy is a type of treatment using the real relationship with the
therapist, education, suggestions, and reinforcements to help a patient cope with
the external world (see Table 39–1) (option A is incorrect). Family therapy is the treat-
ment of a dysfunctional unit (siblings, parent[s], step- or half-siblings, originally
targeted child, other key figures) (option B is incorrect). Collaborative therapy in-
volves having one clinician treat a child while one or more other clinicians treat
the parent(s) or sibling(s) (option C is correct). Filial therapy involves the treatment
of a child through the parent (who takes the doctor’s ideas home and tries them
out on the young person) (option D is incorrect). (Chapter 39, Individual Psycho-
therapy/Table 39–1, pp. 850–851)

310 | Individual Psychotherapy—Answer Guide

 C H A P T E R 4 0

Parent Counseling,
Psychoeducation, and
Parent Support Groups
40.1 Psychoeducation originally emerged as a therapeutic component in the treatment
of what psychiatric disorder?

A. Autism.
B. Major depressive disorder.
C. Substance abuse.
D. Schizophrenia.

The correct response is option D: Schizophrenia.

Psychoeducation emerged from efforts to improve the prognosis of schizophrenia

(Option D is correct; options A, B, and C are incorrect). Goldstein et al. (1978) gave
recently discharged adults with schizophrenia and their families a program de-
signed to help them understand the illness and its treatment and plan for future
crises. The approach has since been adapted for the use in treatment of other men-
tal health disorders. (Chapter 40, Parent Counseling, Psychoeducation, and Parent
Support Groups/Parent Counseling and Psychoeducation/History of Psychoedu-
cation, pp. 877–878)

40.2 Psychoeducational programs designed for adults generally require what adapta-
tion to be used in child populations?

A. Lower intensity.
B. Shorter follow-up.
C. Emphasis on improving the home environment.
D. Emphasis on changing the child’s behavior to meet the expectations of the
school environment.

The correct response is option C: Emphasis on improving the home environment.

311
 Psychoeducation in child populations may require age adjustments to programs
developed for adults, including greater intensity (option A is incorrect) and longer
follow-up (option B is incorrect), emphasis on improving the home environment
(option C is correct), and assistance in adjusting environmental expectations,
which may involve adjusting the school environment in order to help the child
succeed despite symptoms (option D is incorrect) (Table 40–1). (Chapter 40, Par-
ent Counseling, Psychoeducation, and Parent Support Groups/Parent Counsel-
ing and Psychoeducation/Table 40–5, p. 881)

TABLE 40–1. Age adjustments needed for psychoeducation with children and
adolescents with mental illness, compared with programs for adults

Psychoeducational adjustments for

children and adolescents Reason for the adjustment

Clarification for the child and family With a much earlier age of onset than adults, children
about what the disorder is and what may not have had an opportunity to develop a
the child’s traits are: distinction healthy identity separate from symptoms
between personality and symptoms
Emphasis on social skills training Children may not have had the opportunity to
develop age-appropriate social skills because of
early onset
Assistance in adjusting environmental Education and intervention are often needed at school
expectations to help adjust the environment to one in which the
child can succeed despite symptoms
Emphasis on the importance of the Children are still dependent on their parents and thus
home environment and how to are particularly vulnerable to unhealthy home
improve it environments
Greater intensity of treatment and Earlier onset often leads to a more pernicious course
longer follow-up and greater treatment resistance
Developmentally appropriate group Children and adolescents differ in their
content developmental level, so separate content or groups
are needed for the two ages
Source. Adapted from Fristad et al. 1996.

40.3 Multifamily psychoeducational psychotherapy (MF-PEP) was developed for use

in what population?

A. Toddlers with pervasive developmental disorders.

B. Preschoolers with behavioral problems.
C. Children with mood disorders.
D. Adolescents with substance use disorders.

The correct response is option C: Children with mood disorders.

MF-PEP was developed as an adjunctive intervention for families of children ages

8–12 years with mood disorders (option C is correct; options A, B, and D are in-
correct). In addition to a reduction in mood symptoms at follow-up, improve-
ments in children participating in MF-PEP included decreases in symptoms of

312 | Parent Counseling and Psychoeducation—Answer Guide

 attention-deficit/hyperactivity disorder, oppositional defiant disorder, and over-
all disruptive behaviors. (Chapter 40, Parent Counseling, Psychoeducation, and
Parent Support Groups/Parent Counseling and Psychoeducation/Example of a
Psychoeducation Intervention, pp. 886–887)

40.4 Parents participating in parent support services find what aspect of the services
to be most helpful?

A. Practical information.
B. Sense of shared purpose or advocacy.
C. Access to specialized mental health care.
D. Emotional support.

The correct response is option D: Emotional support.

A national survey of parents of children with emotional or behavioral disorders

showed that 72% of respondents found emotional support to be the most helpful
aspect of family support services (Friesen and Koroloff 1990) (option D is correct).
Parent support services may also provide parents with practical information (op-
tion A is incorrect) and a sense of shared purpose or advocacy (option B is incor-
rect). Approximately 70% of Americans suffering from mental disorders rely
solely on self- and mutual-help options rather than specialized mental health care
(Norcross 2000) (option C is incorrect). (Chapter 40, Parent Counseling, Psycho-
education, and Parent Support Groups/Parent Support Groups/What Are Parent
Support Groups?, p. 888)

40.5 What is the psychoeducational technique that involves the use of written materi-
als, video, or Web sites to further educate families about mental illness?

A. Bibliotherapy.
B. Naming the enemy.
C. Thinking, feeling, doing.
D. Daily routine tracking.

The correct response is option A: Bibliotherapy.

Bibliotherapy involves using written materials, video, or Web sites to further ed-
ucate families about mental illness (option A is correct) (Table 40–2). Naming the
enemy is a technique that helps the child and parents determine the difference be-
tween the child’s symptoms and his or her own personality (option B is incorrect).
Thinking, feeling, doing is a technique that involves increasing insight of parents
and child into the connections among their thoughts, feelings, and behaviors (op-
tion C is incorrect). Daily routine tracking is a technique used to track daily routines
such as sleep-wake cycles, eating, and other daily activities to determine their ef-
fect on mood and behavior (option D is incorrect). (Chapter 40, Parent Counseling,
Psychoeducation, and Parent Support Groups/Parent Counseling and Psychoed-
ucation/Starting a Multifamily Psychoeducation Group, Table 40–10, p. 890)

Parent Counseling and Psychoeducation—Answer Guide | 313

TABLE 40–2. Examples of techniques used in psychoeducation
Psychoeducational
techniques Description of technique

Bibliotherapy Using written materials, video, or Web sites to further educate

families about mental illness
Daily routine tracking Tracking daily routines such as sleep-wake cycles, eating, and
other daily activities to determine their effect on mood and
behavior
Mood chart Tracking changes in mood, when they occur, and the
circumstances that happen around the time of the changes
Naming the enemya Helping the child and parents determine the difference between
the child’s symptoms and his or her own personality
Thinking, feeling, doinga Increasing insight of parents and child into the connections
among their thoughts, feelings, and behavior
Toolkita Developing a variety of pleasant or relaxing activities for the child
to use in affect regulation
aTechniques used in multifamily psychoeducational psychotherapy.

References
Friesen BJ, Koroloff NM: Family centered services: implications for mental health administration
and research. J Ment Health Adm 17(1):13–25, 1990 10104410
Fristad MA, Gavazzi SM, Centolella DM, et al: Psychoeducation: a promising intervention strat-
egy for families of children and adolescents with mood disorders. Contemp Fam Ther 18(3):
371–384, 1996
Goldstein MJ, Rodnick EH, Evans JR, et al: Drug and family therapy in the aftercare of acute
schizophrenics. Arch Gen Psychiatry 35(10):1169–1177, 1978 211983
Norcross JC: Here comes the self-help revolution in mental health. Psychotherapy 37(4):370–377,
2000

314 | Parent Counseling and Psychoeducation—Answer Guide

 C H A P T E R 4 1

Behavioral Parent Training

41.1 Which contingency-based behavioral key concept involves decreasing a behavior
by following it with something undesirable?

A. Positive reinforcement.
B. Negative reinforcement.
C. Punishment.
D. Extinction.

The correct response is option C: Punishment.

Behavior therapy approaches emphasize the importance of environmental and

social contingencies in fostering and maintaining problem behavior—that is, con-
tingency theory. Contingency-based behavioral interventions involve one or more
of four key concepts: behavior is increased either by following it with something
desirable (positive reinforcement) (option A is incorrect) or by removing something
undesirable (negative reinforcement) (option B is incorrect); behavior is decreased
either by following it with something undesirable (punishment) (option C is cor-
rect) or by removing something desirable (extinction) (option D is incorrect).
(Chapter 41, Behavioral Parent Training/Theoretical Underpinnings and Key
Concepts, p. 901)

41.2 Within what period from the time that parents put initial strategies of behavioral
parent training (BPT) into practice do children typically respond?

A. Several days.
B. Several weeks.
C. Several months.
D. >6 months.

The correct response is option B: Several weeks.

Children typically respond to initial strategies within the first few weeks of the
time that parents put BPT strategies into practice (option B is correct; options A,
C, and D are incorrect). (Chapter 41, Behavioral Parent Training/When to Expect
Response, p. 919)

315
41.3 What is a primary contraindication for behavioral parent training (BPT)?

A. Parent with severe depression.

B. Toddler with oppositionality and comorbid attention-deficit/hyperactivity dis-
order (ADHD).
C. Parent and child with poor attachment.
D. Adolescent with behavioral problems and comorbid anxiety.

The correct response is option A: Parent with severe depression.

The demands of parent training can be substantial, as parents are required to

learn specific procedures and complete homework each week to practice skills
taught during group. As a result, the primary contraindications are parent psy-
chopathology (ADHD, depression), marital discord, or some other type of family
dysfunction that is sufficiently severe that it prevents parents from participating
or making the necessary time investment (option A is correct). BPT is strongly in-
dicated for oppositional and conduct problems and ADHD on the basis of numer-
ous empirical studies (American Psychological Association Working Group on
Psychoactive Medications for Children and Adolescents 2006; Steiner et al. 2007;
Subcommittee on Attention-Deficit/Hyperactivity Disorder et al. 2011). Both
boys and girls spanning the full age range (toddler to adolescent) can benefit from
this approach, although developmental considerations may require modifications
(option B is incorrect). BPT also can be helpful for youth with comorbid internal-
izing problems such as anxiety or depression, although minor modifications may
be made for children presenting primarily with these types of problems (option D is
incorrect). Parent training programs also can address attachment deficiencies be-
tween children and their parents. Lower levels of attachment are theorized to lead
to emotional dysregulation and a lack of mutual responsiveness between parent
and child (Harwood and Eyberg 2004; Herschell et al. 2002). Parent training ad-
dresses these emotional factors by fostering responsiveness, communication, and
nurturance between parent and child. These processes in turn enable the child to
develop secure attachments with others and improved emotional regulation (op-
tion C is incorrect). (Chapter 41, Behavioral Parent Training/Rationale for Using
Parent Training With Disruptive Behavior Disorders, p. 903; Indications, p. 921;
Contraindications, p. 921)

41.4 If a token economy is not initially effective, which of the following would be an
error discovered upon troubleshooting the intervention?

A. The target behavior is defined vaguely to increase the likelihood of success.

B. The goal is set at a level that allows the child to be successful immediately.
C. The reinforcer is given immediately and frequently.
D. The child can get the reinforcer only when earned.

The correct response is option A: The target behavior is defined vaguely to increase
the likelihood of success.

316 | Behavioral Parent Training—Answer Guide

 For clinicians, it is important to be aware that token economies are somewhat sen-
sitive interventions, with minor differences in intervention structure often resulting
in vastly different outcomes and efficacy (Table 41–1). Consequently, if a token
economy is not initially effective, it is important to troubleshoot the intervention
rather than to deem it ineffective and discontinue it. Parents should define the tar-
get behavior clearly in observable, positive terms (option A is correct). Parents must
set the criteria for earning the tokens or rewards low enough that the child is able
to regularly obtain rewards; if the behaviors are too difficult relative to the child’s
current functioning, the child likely will become discouraged and the system will
not work (option B is incorrect). Reinforcement needs to occur as often as necessary
to ensure goals are met and soon after the behavior (option C is incorrect). The child
should be motivated by the reinforcer and should not be able to have it without
earning it (option D is incorrect). (Chapter 41, Behavioral Parent Training/Token
Economy or Point System, p. 907; Troubleshooting, p. 909; Table 41–1, p. 911)

41.5 Which of the following is a theoretical underpinning and key concept in behav-
ioral parent training (BPT)?

A. Behavioral therapy approaches emphasize classical conditioning theory.

B. Behavioral interventions usually begin with a functional behavior analysis, which
involves specifying behaviors and then identifying each behavior’s antecedents
and consequences.
C. Maximally effective interventions do not consider the function of the problem
behavior when attempting to reduce it.
D. The behavioral approach to intervention selects target diagnostic symptoms for
treatment.

The correct response is option B: Behavioral interventions usually begin with

a functional behavior analysis, which involves specifying behaviors and then
identifying each behavior’s antecedents and consequences.

Behavior therapy approaches emphasize the importance of environmental and

social contingencies in fostering and maintaining problem behavior—that is, con-
tingency theory (option A is incorrect). Behavioral interventions usually begin with
a functional behavior analysis, which involves specifying behaviors (positive behav-
iors to increase or negative behaviors to decrease) and then identifying each be-
havior’s antecedents (variables setting the stage for or preceding the behavior) and
consequences (variables maintaining the behavior) (option B is correct). Maximally
effective behavioral interventions consider the function of the problem behavior
when attempting to reduce it (option C is incorrect). Generally, the behavioral ap-
proach to intervention selects target behaviors for treatment that cause impairment
in daily living (e.g., academic, social behavior) rather than targeting diagnostic
symptoms per se, although it is important to note that these interventions often
do have powerful direct and indirect effects on diagnostic symptoms (option D is
incorrect). (Chapter 41, Behavioral Parent Training/Theoretical Underpinnings
and Key Concepts, pp. 901–902)

Behavioral Parent Training—Answer Guide | 317

 TABLE 41–1. Troubleshooting token economies
Question Solution

Is the target behavior defined very clearly? Define target behavior in observable, positive terms.
Is the goal set too high? Set goal at a level that allows the child to be successful immediately.
Is the child motivated by the reinforcer and not able to have it Make sure the child wants the reinforcer and can get it only when earned.
without earning it?
Does the child understand the program? Have the child repeat all steps of the program, including goals and
reinforcers.
Is the child overly anxious about the program or complaining that Make sure goals are within the child’s reach and ignore the child’s
it is too hard? complaining if it is intended to get the parents to stop the program.
Is the child interested in the reinforcer? Make sure the child wants the reinforcer.
Is the reinforcer given immediately and frequently? Reinforcement needs to occur as often as necessary to ensure goals are met
and soon after the behavior.
Are there other factors maintaining the problem behavior (e.g., get- Address any competing factors directly.
ting peer attention, getting out of doing work, getting someone
else to do it for him or her)?

318 | Behavioral Parent Training—Answer Guide

Did the child do well for a while and then start to backslide? Encourage parents to consider changing consequences to something more
meaningful but to be consistent in keeping the program in place.
Are all caretakers supporting the program? Communicate with caretakers in addition to the parents (e.g., grandparents,
babysitters) so that everyone understands the program and can support it.
Did the child start having more problems when the reward program Successfully fading a program is a gradual process (e.g., via gradual increases
was being faded? in requirements for rewards) and should be presented to the child as a
positive accomplishment. Expect that some contingencies may always need
to be in place for optimal outcomes.
References
American Psychological Association Working Group on Psychoactive Medications for Children
and Adolescents: Psychopharmacological, Psychosocial, and Combined Interventions for
Childhood Disorders: Evidence Base, Contextual Factors, and Future Directions. Report of
the Working Group on Psychoactive Medications for Children and Adolescents. Washington,
DC, American Psychological Association, 2006
Harwood MD, Eyberg SM: Therapist verbal behavior early in treatment: relation to successful
completion of parent-child interaction therapy. J Clin Child Adolesc Psychol 33(3):601–612,
2004 15271617
Herschell AD, Calzada EJ, Eyberg SM, et al: Parent-child interaction therapy: new directions in re-
search. Cogn Behav Pract 9:9–16, 2002
Steiner H, Remsing L, American Academy of Child and Adolescent Psychiatry Work Group on
Quality Issues: Practice parameter for the assessment and treatment of children and adoles-
cents with oppositional defiant disorder. J Am Acad Child Adolesc Psychiatry 46(1):126–141,
2007 17195736
Subcommittee on Attention-Deficit/Hyperactivity Disorder et al: ADHD: clinical practice guide-
line for the diagnosis, evaluation and treatment of attention deficit/hyperactivity disorder in
children and adolescents. Pediatrics 128(5):1007–1022, 2011 22003063

Behavioral Parent Training—Answer Guide | 319

 C H A P T E R 4 2

Family-Based Assessment
and Treatment
42.1 During the early to mid twentieth century, what led to the belief that parents
should not be involved in child treatment?

A. Parents were regarded as the cause of their child’s psychological or psychiatric

problems.
B. Research had established that family involvement negatively affected treat-
ment engagement and dropout rates in child mental health.
C. Research had found that integration of parent support into child treatment led
to child symptom exacerbation.
D. Research had found that integration of parent support into child treatment led
to parental dissatisfaction with the treatment.

The correct response is option A: Parents were regarded as the cause of their
child’s psychological or psychiatric problems.

During the early to mid twentieth century, largely as a function of the influence
of psychoanalysis, it was believed that parents should not be involved in child
treatment because they were regarded as the cause of their child’s psychological
or psychiatric problems (option A is correct). This attitude was replaced during
the 1950s and 1970s as research and practice revealed the enormous impact par-
ents and other family members have on the well-being of children. Research has
established that family functioning and involvement powerfully affect treatment
engagement and dropout rates in child mental health (Brookman-Frazee et al.
2008) (option B is incorrect). In a meta-analysis of published studies involving
family support in children’s mental health, Hoagwood et al. (2010) found that
when parent support was integrated into child treatment, overall results were
positive for child symptom reduction (option C is incorrect), parental satisfaction
with the treatment (option D is incorrect), improved parenting skills, parental
knowledge of the child’s illness, and perceived social support. (Chapter 42, Fam-
ily-Based Assessment and Treatment, pp. 937–938)

321
42.2 What concept involves the provision of a safe and need-fulfilling social context
within which the infant and young child can develop?

A. Negative affective reciprocity.

B. Systems principle.
C. Multilevel principle.
D. Holding environment.

The correct response is option D: Holding environment.

Negative affective reciprocity (perceiving negative emotion from someone and am-
plifying one’s in-kind response) has been found to be frequently associated with
lower levels of attachment and relational stability (option A is incorrect). The sys-
tems principle states that “psychopathology arises from complex interactions
...between the individual and the multiple systems in which the life of the indi-
vidual is embedded” (Masten 2006, p. 48), while the multilevel principle argues that
“processes involved in psychopathology occur within and across multiple lev-
els of functioning, from the molecular or genetic to cultural or societal systems”
(Masten 2006, p. 48) (options B and C are incorrect). A central component of Winn-
icott’s (1965) theory is the holding environment: that is, the provision of a safe and
need-fulfilling social context within which the infant and young child can de-
velop. The creation of this holding environment requires an early and primary pa-
rental preoccupation in order to facilitate the growth of children, which gradually
recedes as the child matures (option D is correct). (Chapter 42, Family-Based As-
sessment and Treatment/Key Concepts, p. 940; The Social Environment for Chil-
dren and Adolescents, pp. 940–941)

42.3 Which of the following has been identified in dyadic and family-based treatments
as enhancing positive outcome?

A. Creating good alliance with the family members who demonstrate the most
motivation for change.
B. Conceptualizing problems to be the responsibility of the identified patient.
C. Slowing down and softening the interactive and emotional processes.
D. Encouraging personal responsibility solely for positive processes.

The correct response is option C: Slowing down and softening the interactive
and emotional processes.

In dyadic and family-based treatments the following have been identified as en-
hancing positive outcome: involving others in treatment, creating good alliances
with pertinent family members (option A is incorrect), conceptualizing problems
in terms of social interaction (option B is incorrect), disrupting harmful relational
cycles, ensuring agreement on tasks and treatment goals, helping all members see
their part in negative patterns, slowing down and softening the interactive and
emotional processes (option C is correct), and encouraging personal responsibil-
ity for negative and positive processes (option D is incorrect) (Sprenkle et al.

322 | Family-Based Assessment and Treatment—Answer Guide

 2009). (Chapter 42, Family-Based Assessment and Treatment/Common Factors
and Mechanisms of Change, p. 942)

42.4 What tenet did Jay Lebow highlight in his influential 1997 article identifying a
dramatic change in family therapy practice?

A. Clinicians should practice within one theoretical model or treatment modality.

B. Clinicians should remain loyal to older theoretical models.
C. Clinicians should abandon empirically supported treatments.
D. Clinicians should be integrative and “do what works.”

The correct response is option D: Clinicians should be integrative and “do what
works.”

Jay Lebow’s (1997) influential article identified a dramatic change in family ther-
apy practice, which he described as an “integrative revolution in couple and family
therapy” (p. 1). He called attention to empirically supported treatments, evidence-
based practice, and best practice standards that have led clinicians to “do what
works” rather than be loyal to and practice within one of the older theoretical models
(option D is correct; options A, B, and C are incorrect). Since the late 1990s, integra-
tive empirically supported practice has superseded the classic models. Treatments
today commonly employ a multimodal approach and draw from a variety of perti-
nent empirically supported treatments. (Chapter 42, Family-Based Assessment
and Treatment/Integrative Module-Based Family Therapy, p. 946)

42.5 What is a distinguishing aspect of Integrative Module-Based Family Therapy

(IMBFT)?

A. While involving domains that are empirically established or reasonably as-

sumed mechanisms of change, it typically is considered to be less comprehen-
sive than other forms of family therapy.
B. It typically focuses on the specific family to the exclusion of the role that cul-
ture, socioeconomic level, immigration status, religion, race, gender, and sex-
ual orientation can play in producing and maintaining psychopathology.
C. Despite the inclusion of a step-by-step assessment instrument, it was designed
to be flexible and responsive to changing clinical presentations or new chal-
lenges that affect treatment.
D. It is a self-contained treatment modality that obviates the need for the clinician
to search the literature and/or use additional tools (e.g., symptom rating
scales, standard checklists, etc.).

The correct response is option C: Despite the inclusion of a step-by-step assess-

ment instrument, it was designed to be flexible and responsive to changing
clinical presentations or new challenges that affect treatment.

IMBFT describes 10 areas referred to as domains in which there are empirically es-
tablished or reasonably assumed mechanisms of change. By employing 10 domains,

Family-Based Assessment and Treatment—Answer Guide | 323

 IMBFT is more comprehensive than other forms of family therapy, whether they
are the classical models or more narrowly defined family-based empirically sup-
ported treatments (option A is incorrect). One of the 10 domains, the community
domain, encompasses the need for family therapists to be sensitive to the role that
culture, socioeconomic level, immigration status, religion, race, gender, and sex-
ual orientation play in creating conditions that produce or maintain psychopathol-
ogy. Even when this domain is not the prime focus of intervention, it is important
that it be considered as a frame for working within all the other domains (option
B is incorrect). IMBFT does involve the use of a step-by-step assessment instru-
ment but was designed to be flexible and, therefore, responsive to changing clin-
ical presentations or new challenges that affect treatment (option C is correct).
Once a domain is selected as the focus for beginning intervention, the clinician is
encouraged to search the literature (e.g., Medline and PsycINFO) or practice guide-
lines to determine the best applicable therapies or empirically supported treat-
ments. Following the choice of domain and subsequent modular intervention, it
is important that the clinician assess progress using standard outcome measures
such as ratings of symptoms, standard checklists, or regular discussions with the
family concerning movement toward shared therapeutic goals (option D is incor-
rect). (Chapter 42, Family-Based Assessment and Treatment/Integrative Module-
Based Family Therapy, pp. 946–948; Implementing Integrative Module-Based
Family Therapy, pp. 948–949)

References
Brookman-Frazee L, Haine RA, Gabayan EN, et al: Predicting frequency of treatment visits in
community-based youth psychotherapy. Psychol Serv 5(2):126–138, 2008 20396643
Hoagwood KE, Cavaleri MA, Serene Olin S, et al: Family support in children’s mental health: a
review and synthesis. Clin Child Fam Psychol Rev 13(1):1–45, 2010 20012893
Lebow J: The integrative revolution in couple and family therapy. Fam Process 36(1):1–17, discus-
sion 19–24, 1997 9189750
Masten AS: Developmental psychopathology: pathways to the future. Int J Behav Dev 30(1):47–54,
2006 20576187
Sprenkle DH, Davis SD, Lebow JL: Common Factors in Couple and Family Therapy: The Over-
looked Foundation for Effective Practice. New York, Guilford, 2009
Winnicott DW: The Maturational Processes and the Facilitating Environment: Studies in the The-
ory of Emotional Development. Oxford, UK, International Universities Press, 1965

324 | Family-Based Assessment and Treatment—Answer Guide

 C H A P T E R 4 3

Interpersonal Psychotherapy
for Depressed Adolescents
43.1 What is the main treatment focus of interpersonal psychotherapy for depressed
adolescents (IPT-A)?

A. Changing maladaptive beliefs and attitudes, eliminating emotional distress,

and alleviating social skill deficits and avoidance behaviors.
B. Improving the adolescent’s relationships by teaching communication and in-
terpersonal problem-solving skills that can lead to a reduction in the adoles-
cent’s depressive symptoms.
C. Strengthening a person’s own motivation and commitment to change.
D. Internal conflict, the unconscious, repetition compulsion, and transference.

The correct response is option B: Improving the adolescent’s relationships by

teaching communication and interpersonal problem-solving skills that can
lead to a reduction in the adolescent’s depressive symptoms.

The specific interventions used in cognitive-behavioral therapy (CBT) are indi-

vidually tailored and strategically directed toward changing maladaptive beliefs
and attitudes, eliminating emotional distress, and alleviating social skill deficits
and avoidance behaviors (option A is incorrect). IPT-A focuses on improving the
adolescent’s relationships by teaching communication and interpersonal prob-
lem-solving skills that can lead to a reduction in the adolescent’s depressive
symptoms (option B is correct). Motivational interviewing is “a collaborative con-
versation style for strengthening a person’s own motivation and commitment to
change” (Miller and Rollnick 2013, p. 12) (option C is incorrect). Psychodynamic
psychotherapy is the psychological treatment of a child, based on such Freudian
principles as internal conflict, the unconscious, repetition compulsion, and trans-
ference (option D is incorrect). (Chapter 39, Individual Psychotherapy/Table 39–1,
p. 850; Chapter 43, Interpersonal Psychotherapy for Depressed Adolescents/Course
of Treatment: Initial Phase (Sessions 1–4)/Explain the Theory and Goals of IPT-A,
p. 961; Chapter 44, Cognitive-Behavioral Treatment for Anxiety and Depression/
General Characteristics of Cognitive-Behavioral Treatment, pp. 973–974; Chapter
45, Motivational Interviewing/Motivational Interviewing Described, p. 993)

325
43.2 What process is involved in the initial phase of interpersonal psychotherapy for
depressed adolescents (IPT-A) in providing psychoeducation about depression to
an adolescent?

A. Confirming the depression diagnosis.

B. Assigning the adolescent the limited sick role.
C. Identifying effective strategies for managing the problem and practicing and
implementing the strategies.
D. Discussing the possibility of recurrence of depression, the warning symptoms
of depression that are particular to that adolescent, and strategies for manag-
ing a recurrence.

The correct response is option B: Assigning the adolescent the limited sick role.

Prior to entering IPT-A, the adolescent should have already completed a full psy-
chiatric evaluation to assess current symptoms and diagnoses, as well as psychi-
atric, family, developmental, medical, social, and academic history. However, it is
important to confirm the depression diagnosis in the first session, using a clinical
interview (option A is incorrect). Psychoeducation includes assigning the adoles-
cent the limited sick role (option B is correct). This involves explaining that like
someone with a medical illness, adolescents who have symptoms of depression
may not be able to do as many things or do things as well as they did before the
depression developed. The goal of the limited sick role is for the adolescent to try
to do as many of his or her usual activities as possible, with the awareness and ac-
ceptance that he or she might not do these things as often or as well as before the
depression developed. During the middle phase of treatment, the therapist and
adolescent begin to work directly on the identified interpersonal problem area(s).
This is accomplished by identifying effective strategies for managing the problem
and practicing and implementing the strategies (option C is incorrect). The termi-
nation phase of IPT-A involves reviewing the course of the adolescent’s depres-
sive symptoms and how these symptoms have changed. As part of termination,
it is also important to discuss the adolescent’s feelings about ending treatment and
the relationship with the therapist. Finally, the therapist and adolescent should dis-
cuss the possibility of recurrence of depression, the warning symptoms of depression
that are particular to that adolescent, and strategies for managing a recurrence
(option D is incorrect). (Chapter 43, Interpersonal Psychotherapy for Depressed
Adolescents/Course of Treatment, pp. 960–966)

43.3 What is the purpose of the interpersonal inventory?

A. To identify ways in which an adolescent’s communication is problematic and

skills the adolescent needs to master to have more satisfying relationships.
B. To select an interpersonal situation that is causing the adolescent problems,
determine the goal, generate a list of alternative strategies, evaluate the pros
and cons of each potential solution or strategy, and select a strategy to try.

326 | Interpersonal Psychotherapy for Depressed Adolescents—Answer Guide

 C. To identify the interpersonal issues that are most closely related to the adoles-
cent’s depression.
D. To practice the communication and interpersonal problem-solving skills.

The correct response is option C: To identify the interpersonal issues that are
most closely related to the adolescent’s depression.

Communication analysis is used to explore the adolescent’s patterns of interact-

ing with others in order to identify ways in which his or her communication is
problematic and skills the adolescent needs to master to have more satisfying re-
lationships (option A is incorrect). Decision analysis involves selecting an inter-
personal situation that is causing the adolescent problems, determining the goal,
generating a list of alternative strategies (some of these may come out of the com-
munication analysis), evaluating the pros and cons of each potential solution or
strategy, and selecting a strategy to try first in session and then, if it looks promis-
ing, outside of the session (option B is incorrect). The interpersonal inventory is
used to identify the interpersonal issues that are most closely related to the ado-
lescent’s depression (option C is correct). Role-playing is a way for adolescents to
practice the communication and interpersonal problem-solving skills that they
have learned in order to feel more comfortable using them in real life (option D is
incorrect). (Chapter 43, Interpersonal Psychotherapy for Depressed Adolescents/
Course of Treatment, pp. 961, 964)

43.4 In which interpersonal problem area are renegotiation, impasse, and dissolution
stages described?

A. Grief due to death.

B. Interpersonal role disputes.
C. Interpersonal role transitions deficits.
D. Interpersonal deficits.

The correct response is option B: Interpersonal role disputes.

On the basis of the interpersonal inventory, the therapist and the adolescent iden-
tify one of four interpersonal problem areas that will be the focus of treatment.
Grief due to death is selected as the problem area when an adolescent experiences
the death of a loved one and the loss is associated with normal bereavement or
prolonged grief, significant depressive symptoms, and impairment in functioning
(option A is incorrect). Interpersonal role disputes is selected as the problem area if
the adolescent’s depressive episode coincides with a relationship conflict. An ad-
olescent may present with interpersonal role disputes that may be in one of three
stages: renegotiation, impasse, or dissolution (option B is correct). An adolescent
and significant other are in the renegotiation stage if they are still communicating
with one another and are attempting to resolve the conflict. They are in the impasse
stage if they are no longer attempting to negotiate the conflict and social distanc-
ing (or “the silent treatment”) has occurred. In the dissolution stage, the adolescent
and significant other have already decided that the dispute cannot be resolved,

Interpersonal Psychotherapy for Depressed Adolescents—Answer Guide | 327

 and they have chosen to end the relationship. An interpersonal role transition oc-
curs when a life change requires an alteration of behavior from an old role to a
new role. An adolescent may develop symptoms of depression in response to a
role transition if the role is unexpected or undesired, the adolescent is not psycho-
logically or emotionally prepared for the new role, or the adolescent preferred the
old role (option C is incorrect). Interpersonal deficits refer to underdeveloped social
and communication skills that impair the adolescent’s ability to have positive rela-
tionships. Deficits may include difficulty initiating or maintaining relationships,
verbally expressing one’s feelings or needs, or eliciting information from others to
establish communication (option D is incorrect). (Chapter 43, Interpersonal Psy-
chotherapy for Depressed Adolescents/Course of Treatment, pp. 962–965)

43.5 For which patients is interpersonal psychotherapy for depressed adolescents

(IPT-A) most effective?

A. Adolescents with a primary diagnosis of anxiety and comorbid depression.

B. Adolescents with a primary diagnosis of bipolar disorder with a current de-
pressive episode.
C. Adolescents with a primary diagnosis of depression and concurrent passive
suicidal thoughts.
D. Adolescents with a primary diagnosis of depression and comorbid intellectual
disability.

The correct response is option C: Adolescents with a primary diagnosis of de-

pression and concurrent passive suicidal thoughts.

IPT-A is a developmental adaptation that is designed to treat adolescents, ages

12–18 years, with nonpsychotic, unipolar depression. Depressed adolescents with
comorbid anxiety disorders, attention-deficit/ hyperactivity disorder, and oppo-
sitional defiant disorder have been successfully treated with IPT-A, although IPT-
A is most effective when depression is the primary diagnosis (option A is incor-
rect). IPT-A is not recommended for adolescents who have intellectual disability,
active suicidal or homicidal thoughts with a plan and/or intent, psychosis, or bi-
polar disorder or are actively abusing substances (option C is correct; options B
and D are incorrect). (Chapter 43, Interpersonal Psychotherapy for Depressed
Adolescents, p. 960)

Reference
Miller WR, Rollnick S: Motivational Interviewing, 3rd Edition. New York, Guilford, 2013

328 | Interpersonal Psychotherapy for Depressed Adolescents—Answer Guide

 C H A P T E R 4 4

Cognitive-Behavioral
Treatment for Anxiety and
Depression
44.1 Which is the process by which a child may acquire a fear by observing another
person behaving fearfully?

A. Classical conditioning.
B. Operant conditioning.
C. Vicarious conditioning.
D. Cognitive restructuring.

The correct response is option C: Vicarious conditioning.

There are several different theoretical models that are considered to play a role in
the etiology of anxiety disorders. Vicarious conditioning (observational learning) is
the process whereby a child may acquire a fear by observing another person be-
having fearfully—if a parent behaves fearfully during a thunderstorm, a child
may acquire a fear of thunderstorms (option C is correct). One of the most influ-
ential explanations for the etiology and maintenance of anxiety disorders is Mow-
rer’s (1947) two-factor theory. Mowrer hypothesized that fears may be acquired
by classical conditioning but are maintained by operant conditioning, where es-
cape or avoidance behaviors eliminate physical and psychological distress. For
example, Jackie has a fear of dogs, which developed because a dog once suddenly
jumped on her, creating a startle reaction (her heart began to race, she could not
catch her breath, and so forth). Her fear developed because of classical condition-
ing. Now, when playing outside, Jackie sees a dog and becomes anxious (option
A is incorrect). If Jackie runs away, her anxiety dissipates. In turn, the feeling of
relief increases the likelihood that in the future, Jackie will run away when she
sees a dog. Therefore, her fear is maintained by operant conditioning—she acts on
her environment, and by her actions, she maintains her fear (option B is incorrect).
These same theoretical models—classical conditioning, operant conditioning,
and vicarious conditioning—form the underpinnings of CBT. Cognitive restructur-

329
 ing is based on the theory that negative thoughts can affect the emotional and be-
havioral response to the anxiety-provoking situations. The goal of treatment is to
restructure faulty cognitions, which in turn should decrease subjective distress
and eliminate avoidance behavior. The first step of cognitive restructuring is to
help youth become aware of these maladaptive thoughts. On the basis of Socratic
questioning, therapists help youth recognize errors in logic and see how particular
beliefs may be maladaptive. In some cases, alternative (e.g., coping) statements
may be used to counteract the negative thoughts (option D is incorrect). (Chapter
44, Cognitive-Behavioral Treatment for Anxiety and Depression/General Char-
acteristics of Cognitive-Behavioral Treatment/Anxiety Disorders, pp. 974–975)

44.2 Over the course of several weeks, a 7-year-old girl with social anxiety disorder
has worked her way with her therapist through her social anxiety “ladder.” She
has worked on speaking to staff at the clinic with and then without her therapist
and then on speaking to the familiar cashier at a neighborhood store with and
then without her therapist. She next plans to speak to a stranger on the street be-
fore finally speaking in front of her class at school. This therapeutic approach il-
lustrates which of the following cognitive-behavioral therapy (CBT) strategies?

A. Social skills training.

B. Graduated exposure.
C. Relaxation training.
D. Cognitive restructuring.

The correct response is option B: Graduated exposure.

Exposure is a procedure whereby the individual is placed in contact with the ob-
ject or situation that elicits fear or distress. Graduated exposure is based on a classi-
cal conditioning paradigm whereby situations that elicit a low level of fear are
introduced first, followed over time by situations that elicit more intense fear. As
the number of times that the child confronts the situation increases, even former
“high fear” items no longer elicit distress (option B is correct). Social skills training
is a procedure used to address social skill deficits that often accompany social
anxiety. Using modeling, role-play, and corrective feedback, children practice
conversational skills such as starting a conversation, asking questions, and being
assertive. Nonverbal skills such as eye contact and vocal tone and volume are also
taught when necessary (option A is incorrect). Another behavioral intervention is
relaxation training, a procedure in which children learn to decrease their physio-
logical and subjective arousal by engaging in either muscle tension-relaxation se-
quences or cognitive meditation (option C is incorrect). Cognitive restructuring is
based on the theory that negative thoughts can affect the emotional and behav-
ioral response to the anxiety-provoking situations. The goal of treatment is to re-
structure faulty cognitions, which in turn should decrease subjective distress and
eliminate avoidance behavior (option D is incorrect). The first step of cognitive re-
structuring is to help youth become aware of these maladaptive thoughts. On the
basis of Socratic questioning, therapists help youth recognize errors in logic and

330 | Cognitive-Behavioral Treatment for Anxiety and Depression—Answer Guide

 see how particular beliefs may be maladaptive. In some cases, alternative (e.g.,
coping) statements may be used to counteract the negative thoughts. (Chapter 44,
Cognitive-Behavioral Treatment for Anxiety and Depression/General Charac-
teristics of Cognitive-Behavioral Treatment/Anxiety Disorders, pp. 974–975)

44.3 Research does not yet support the use of cognitive-behavioral therapy (CBT) for
which age group?

A. Very young children (e.g., ages 3–5 years) with depression.

B. Children (e.g., ages 7–11 years) with anxiety.
C. Adolescents (e.g., ages 12–17 years) with depression.
D. Adolescents (e.g., ages 12–17 years) with anxiety.

The correct response is option A: Very young children (e.g., 3–5 years) with de-
pression.

To date, most randomized controlled trials (RCTs) demonstrate that CBT is supe-
rior to wait list and no-treatment control conditions, and CBT is considered an ef-
ficacious treatment for anxiety and depressive disorders. The Child/Adolescent
Anxiety Multimodal Study (CAMS) examined the efficacy of CBT (Coping Cat),
sertraline, the combination of CBT and sertraline, or placebo in a six-site RCT con-
sisting of 488 children and adolescents. After 12 weeks of treatment, 80.7% of chil-
dren treated with combination therapy were judged to be much or very much
improved, as were 59.7% of the CBT group, 59.4% of the sertraline group, and
23.7% of the placebo group (Walkup et al. 2008). In effect, all interventions were
superior to pill placebo, and the combination group was superior to either of the
monotherapies (options B and D are incorrect). There are fewer RCTs examining
the efficacy of CBT for depressive disorders than for the anxiety disorders. Fur-
thermore, data from two meta-analyses (Chu and Harrison 2007; Watanabe et al.
2007) suggest that the effectiveness of CBT for childhood depressive disorders is
less than that of CBT for anxiety disorders. The Adolescent Coping With Depres-
sion Course (CWD-A; Clarke et al. 1990) is a group treatment designed to have a
classroom rather than clinical feel. Each participant has a student workbook. The
first study evaluating the program’s efficacy (Lewinsohn et al. 1990) compared
three conditions: the treatment of adolescents alone, the treatment of adolescents
with a parallel parent group, and a wait list control. Adolescents treated with
CWD-A demonstrated significant reductions in depressive symptoms relative to
those in the control condition. These gains were maintained at 2-year follow-up.
The CWD-A has been refined over the past 15 years, and it can be quite effective
for treating mild to moderate depression in some teens. The multisite Treatment for
Adolescents With Depression Study (TADS) was an RCT funded by the National In-
stitute of Mental Health (NIMH) that examined the effectiveness of individual CBT
in comparison with fluoxetine, placebo, and the combination of fluoxetine and CBT
(March et al. 2007; Treatment for Adolescents With Depression Study Team 2003).
Treatment was conducted with individual teens with optional family sessions. After
12 weeks, TADS CBT did not lead to more improvement in depression than the other

Cognitive-Behavioral Treatment for Anxiety and Depression—Answer Guide | 331

 TADS treatments (March et al. 2007). Youth who received any of the active treat-
ments maintained their gains over 36 weeks. Another NIMH multicenter trial, the
Treatment of SSRI-Resistant Depression in Adolescents (TORDIA), compared the
outcomes of switching medication, adding another medication, or adding CBT to
any medication class when adolescents with depression did not respond to initial
treatment with a selective serotonin reuptake inhibitor (SSRI). Adding CBT plus
switching medications yielded a higher response rate (54.8%) than a medication
switch alone (40.5%) (Brent et al. 2008). Subsequent to the initial study findings, in
an effort to enhance CBT’s efficacy, data analyses determined specific CBT elements
that contributed to the positive outcome (Kennard et al. 2009). The results indicated
that adolescents were 2.5 times more likely to benefit from CBT if they attended at
least 9 out of 12 sessions. As with medication, participating in the treatment as pre-
scribed is necessary for the intervention to be successful. Furthermore, even when
controlling for number of sessions, the adolescents were 2.3 times more likely to have
a positive benefit if they had received problem-solving training and 2.6 times more
likely to have a positive benefit if they had participated in social skills training
(option C is incorrect). Research has not yet supported the use of CBT with very
young children with depression (e.g., ages 3–5 years) or among youth with a severe
learning disability or developmental delay (option A is correct). Some young children
may not have the mental ability necessary to engage in metacognition (thinking
about thinking), which is a necessary element of cognitive restructuring (Alfano
et al. 2002). Fortunately, the elimination of this component from some CBT programs
for anxiety disorders does not reduce the efficacy of the overall program (Spence et
al. 2000). (Chapter 44, Cognitive-Behavioral Treatment for Anxiety and Depres-
sion/Empirical Support, pp. 978–982; Developmental and Gender Considerations,
p. 984)

44.4 When compared to other anxiety disorders, which anxiety disorder in youth may
present unique treatment challenges and may not be most efficaciously treated
with a generic or transdiagnostic intervention strategy?

A. Generalized anxiety disorder.

B. Specific phobia.
C. Separation anxiety disorder.
D. Social anxiety disorder.

The correct response is option D: Social anxiety disorder.

The smaller treatment response for youth with social anxiety disorder in the
Child/Adolescent Anxiety Multimodal Study trial (Ginsburg et al. 2011) is not an
isolated finding. An independent sample of youth with a social anxiety disorder
diagnosis or symptoms treated with cognitive-behavioral therapy (Coping Cat)
demonstrated initial symptom improvement but were significantly less improved
than children with other anxiety disorders at 7.4-year follow-up (Kerns et al. 2013).
The outcome of these two investigations, among several others, suggests that so-
cial anxiety disorder may present unique treatment challenges and may not be most

332 | Cognitive-Behavioral Treatment for Anxiety and Depression—Answer Guide

 efficaciously treated with a generic or transdiagnostic intervention strategy (op-
tion D is correct; options A, B, and C are incorrect). The data suggest that there
may be something unique about social anxiety disorder and that attention to im-
proving social interaction/communication skills, as well as decreasing anxiety, may
be the most efficacious strategy for youth with this disorder. (Chapter 44, Cognitive-
Behavioral Treatment for Anxiety and Depression/Empirical Support/Anxiety
Disorders, p. 979)

44.5 Which of the following factors seems to significantly affect cognitive-behavioral

therapy (CBT) treatment outcome for youth with anxiety disorders?

A. Ethnicity.
B. Gender.
C. Socioeconomic status.
D. Parental psychopathology.

The correct response is option D: Parental psychopathology.

Parental psychopathology may affect successful CBT treatment of the child. Symp-
toms of depression, fear, hostility, psychoticism, and paranoia and obsessive-
compulsive tendencies have all been negatively associated with treatment outcome
for children with anxiety disorders (Berman et al. 2000) (option D is correct). In
contrast, sociodemographic variables do not seem to significantly affect CBT treat-
ment outcome for youth with anxiety disorders. Efficacy appears consistent across
ethnicity, gender, and socioeconomic status (Berman et al. 2000; Ferrell et al. 2004;
Pina et al. 2003) (options A, B, and C are incorrect). (Chapter 44, Cognitive-Behav-
ioral Treatment for Anxiety and Depression/Factors Affecting Outcome, p. 986)

44.6 Which of the following has been established regarding BRAVE-Online, an Inter-
net-based cognitive-behavioral therapy (CBT) program developed for delivery to
youth with anxiety disorders?

A. In a sample of adolescents, BRAVE-Online was less effective in decreasing

anxiety than was BRAVE delivered in the clinic.
B. BRAVE-Online is less effective for youth with severe anxiety than for youth with
anxiety of less severity.
C. In a sample of 7- to 12-year-old children, BRAVE-Online led to small positive
changes.
D. BRAVE-Online was more effective in a sample of 7- to 12-year-old children than
it was for a sample of adolescents.

The correct response is option C: In a sample of 7- to 12-year-old children, BRAVE-

Online led to small positive changes.

As computers and Web access technology now permeate the environment, re-
searchers are beginning to examine how to harness this technology for transport-
ability, dissemination, and positive treatment outcome. BRAVE-Online is a CBT

Cognitive-Behavioral Treatment for Anxiety and Depression—Answer Guide | 333

 program developed for delivery to children (ages 8–12) or adolescents (ages 13–17)
with anxiety disorders (Spence et al. 2008). The program includes relaxation strat-
egies, coping self-talk and cognitive restructuring, graduated exposure, problem
solving, and self-reinforcement of brave behavior. In a sample of adolescents,
BRAVE delivered in the clinic or online was equally effective in decreasing anxi-
ety symptoms and anxiety disorders (option A is incorrect). At 12-month follow-
up, 78% of adolescents treated with the online version no longer met criteria for
their principal diagnosis compared with 80% treated in the clinic (Spence et al.
2011). It should be noted, however, that children whose anxiety disorder was rated
as “severe” by diagnostic clinicians were excluded from this treatment trial be-
cause one of the randomized groups would not be seen in the clinic. Therefore,
the efficacy of this computer-based intervention for youth with the most severe anxi-
ety disorders is not known (option B is incorrect). Additionally, an randomized
controlled trial with 7- to 12-year-old children with anxiety disorders resulted in
small positive changes after the BRAVE-Online program (March et al. 2009)
(option C is correct) but less than for the adolescent sample (Spence et al. 2011)
(option D is incorrect). (Chapter 44, Cognitive-Behavioral Treatment for Anxiety
and Depression/Transportability and Dissemination, p. 982)

References
Alfano CA, Beidel DC, Turner SM: Cognition in childhood anxiety: conceptual, methodological,
and developmental issues. Clin Psychol Rev 22(8):1209–1238, 2002 12436811
Berman SL, Weems CF, Silverman WK, et al: Predictors of outcome in exposure-based cognitive
and behavioral treatments for phobic and anxiety disorders in children. Behav Ther 31(4):
713–731, 2000
Brent D, Emslie G, Clarke G, et al: Switching to another SSRI or to venlafaxine with or without cog-
nitive behavioral therapy for adolescents with SSRI-resistant depression: the TORDIA ran-
domized controlled trial. JAMA 299(8):901–913, 2008 18314433
Chu BC, Harrison TL: Disorder-specific effects of CBT for anxious and depressed youth: a meta-
analysis of candidate mediators of change. Clin Child Fam Psychol Rev 10(4):352–372, 2007
17985239
Clarke G, Lewinsohn P, Hops H: Leader’s Manual for Adolescent Groups: Adolescent Coping
With Depression Course. Portland, OR, Kaiser Permanente Center for Health Research, 1990.
Available at: http://www.kpchr.org/public/acwd/CWDA_manual.pdf. Accessed June 16,
2009.
Ferrell CB, Beidel DC, Turner SM: Assessment and treatment of socially phobic children: a cross
cultural comparison. J Clin Child Adolesc Psychol 33(2):260–268, 2004 15136189
Ginsburg GS, Kendall PC, Sakolsky D, et al: Remission after acute treatment in children and ado-
lescents with anxiety disorders: findings from the CAMS. J Consult Clin Psychol 79(6):806–
813, 2011 22122292
Kennard BD, Clarke GN, Weersing VR, et al: Effective components of TORDIA cognitive-behav-
ioral therapy for adolescent depression: preliminary findings. J Consult Clin Psychol 77(6):
1033–1041, 2009 19968380
Kerns CM, Read KL, Klugman J, et al: Cognitive behavioral therapy for youth with social anxiety:
differential short and long-term treatment outcomes. J Anxiety Disord 27(2):210–215, 2013
23474911
Lewinsohn P, Clarke G, Hops H, et al: Cognitive-behavioral treatment for depressed adolescents.
Behav Ther 21(4):385–401, 1990

334 | Cognitive-Behavioral Treatment for Anxiety and Depression—Answer Guide

March JS, Silva S, Petrycki S, et al: The Treatment for Adolescents With Depression Study (TADS):
long-term effectiveness and safety outcomes. Arch Gen Psychiatry 64(10):1132–1143, 2007
17909125
March S, Spence SH, Donovan CL: The efficacy of an Internet-based cognitive-behavioral therapy
intervention for child anxiety disorders. J Pediatr Psychol 34(5):474–487, 2009 18794187
Mowrer OH: On the dual nature of learning: a reinterpretation of “conditioning” and “problem
solving.” Harv Educ Rev 17:102–148, 1947
Pina AA, Silverman WK, Fuentes RM, et al: Exposure-based cognitive-behavioral treatment for
phobic and anxiety disorders: treatment effects and maintenance for Hispanic/Latino relative
to European-American youths. J Am Acad Child Adolesc Psychiatry 42(10):1179–1187, 2003
14560167
Spence SH, Donovan C, Brechman-Toussaint M: The treatment of childhood social phobia: the ef-
fectiveness of a social skills training-based, cognitive-behavioural intervention, with and
without parental involvement. J Child Psychol Psychiatry 41(6):713–726, 2000 11039684
Spence SH, Donovan CL, March S, et al: Online CBT in the treatment of child and adolescent anx-
iety disorders: issues in the development of BRAVE-ONLINE and two case illustrations. Be-
hav Cogn Psychother 36(special issue 4):411–430, 2008
Spence SH, Donovan CL, March S, et al: A randomized controlled trial of online versus clinic-
based CBT for adolescent anxiety. J Consult Clin Psychol 79(5):629–642, 2011 21744945
Treatment for Adolescents With Depression Study Team: Treatment for Adolescents With Depres-
sion Study (TADS): rationale, design, and methods. J Am Acad Child Adolesc Psychiatry
42(5):531–542, 2003 12707557
Walkup JT, Albano AM, Piacentini J, et al: Cognitive behavioral therapy, sertraline, or a combina-
tion in childhood anxiety. N Engl J Med 359(26):2753–2766, 2008 18974308
Watanabe N, Hunot V, Omori IM, et al: Psychotherapy for depression among children and adoles-
cents: a systematic review. Acta Psychiatr Scand 116(2):84–95, 2007 17650269

Cognitive-Behavioral Treatment for Anxiety and Depression—Answer Guide | 335

 C H A P T E R 4 5

Motivational Interviewing
45.1 What makes motivational interviewing (MI) different from traditional patient-
centered approaches?

A. MI combines outcome with strategy.

B. The theoretical basis for MI is psychodynamic theory.
C. MI typically focuses on education-delivery and provider-centered ideas for
change, as these techniques are known to be effective.
D. MI is deliberate, directional, and goal oriented.

The correct response is option D: MI is deliberate, directional, and goal-oriented.

The usual ways of delivering lifestyle and behavioral counseling, which typically
focus on education delivery and provider-centered ideas for change, are generally
known to be ineffective (option C is incorrect). MI is an alternative approach for
raising problem awareness and facilitating change exploration with individuals
who may be reluctant, stuck, or not yet ready to make behavioral changes. MI
uses a patient-centered, collaborative approach that follows a particular set of
principles and uses specific skills and techniques (Miller and Rollnick 1991). The
theoretical base for MI is self-determination theory (option B is incorrect), and it
is further supported by Truax and Carkaff (1967) and Gordon (1970). The core of
MI instructs the counselor not to confuse outcome with strategy (option A is incor-
rect). While MI adopts a traditional patient-centered style, it is intended to be
more deliberate, directional, and goal oriented (Miller and Rollnick 2013) than
traditional person-centered approaches (option D is correct). (Chapter 45, Moti-
vational Interviewing, pp. 993–994)

45.2 According to the spirit of motivational interviewing (MI), which of the following
should the provider express to, as opposed to evoke from, the patient?

A. Confidence.
B. Empathy.
C. Hope.
D. Action.

The correct response is option B: Empathy.

337
 Providers who genuinely recognize, honor, and express an individual’s worth,
potential, and autonomy through the skillful expression of empathy (option B is
correct) and affirmation have been shown to evoke hope and confidence and em-
power action (options A, C, and D are incorrect). (Chapter 45: Motivational In-
terviewing/Motivational Interviewing Described, p. 995)

45.3 Which of the following interview skills can be a very useful way of guiding
change but in motivational interviewing (MI) is typically only exercised with the
permission and readiness of the patient?

A. OARS.
B. Affirmations.
C. Information sharing.
D. Summaries.

The correct response is option C: Information sharing.

MI uses a cluster of counseling skills referred to as OARS—open-ended ques-

tions, affirmations, reflective listening, and summaries. These core skills are used
both to get to know the patient and to guide and motivate change. Use of these
skills depends on the nature of the interview, the presentation of the patient, and
the stage of the conversational process (options A, B, and D are incorrect). Skills
such as open-ended questions and reflective listening would be used to help with
patient engagement and to promote awareness and understanding. Affirmations
can be helpful to build motivation and inform possibilities by focusing on strengths
and accomplishments. Summaries can assist people in hearing their own change
talk and for collecting and clarifying information, as well as for transitioning to
other topics. Information sharing and advice giving can be a very useful way of
guiding change. In MI, this skill is typically exercised with permission and read-
iness of the patient (option C is correct). (Chapter 45: Motivational Interviewing/
Skills of the Interview: OARS, p. 996)

45.4 How should a provider attempt to resolve parent-child conflict using motivational
interviewing (MI)?

A. Elicit self-motivational statements by asking the “DARN CAT” questions of

the child.
B. Focus on factors within the parent’s control, unless the child is younger than
age 8 years.
C. Relieve discomfort by spreading the blame in a family.
D. Align parent and child in pursuit of a common goal.

The correct response is option D: Align parent and child in pursuit of a common
goal.

Often, a situation that requires change makes all members of a family feel uncom-
fortable. A natural tendency to relieve discomfort is to place the blame elsewhere,

338 | Motivational Interviewing—Answer Guide

 and in a family there may be many people on whom to spread the blame. MI does
not require the provider to address this issue (option C is incorrect). Rather, the
provider should treat blame as any other resistance to change and “roll” with the
resistance while listening for change talk. This forward-looking approach does not
seek to resolve conflict; rather, it aligns the child and parent in pursuit of a common
goal (option D is correct). “DARN CAT” questions are used to elicit self-motiva-
tional statements from the patient (option A is incorrect). Children younger than
age 8 years are concrete in their cognitive developmental abilities and are less able
to discuss causality, link current behavior with future goals, or respond to infer-
ential questions. For these children, the focus should be on factors within the par-
ent’s control (option B is incorrect). (Chapter 45, Motivational Interviewing/
Structure of the MI Interview: The Four Processes/Evoking, p. 998; Specific Ap-
plications, pp. 1000–1002)

45.5 When is it appropriate to negotiate a change with a patient in motivational inter-

viewing (MI)?

A. During agenda-setting.
B. When the situation is serious from a safety perspective.
C. When attempting to focus.
D. When planning for change.

The correct response is option B: When the situation is serious from a safety
perspective.

Agenda-setting consists of the review of roles, purpose, and relevance of the visit
and agreement about topics for discussion (option A is incorrect). Focusing con-
sists of identifying achievable goals to determine the direction of the provider and
patient’s work together (option C is incorrect). During planning the goal is to
move the patient from intention to action by helping with the development of an
effective change plan (option D is incorrect). The provider must be prepared to in-
tervene as needed with regard to the health and safety of the patient. MI can be
used even when the provider acknowledges that he or she is not neutral about the
patient’s choices. Most adolescents will accept that the provider has the responsi-
bility to protect patients. An MI-informed approach can be taken even when com-
municating intention to influence a particular outcome, and depending on the
seriousness of the situation, negotiating a change can be an appropriate strategy
(option B is correct). (Chapter 45, Motivational Interviewing/Structure of the MI
Interview: The Four Processes, pp. 997, 999; Specific Applications, p. 1003)

References
Gordon T: Parent Effectiveness Training. New York, Wyden, 1970
Miller WR, Rollnick S: Motivational Interviewing: Preparing People to Change Addictive Behav-
ior. New York, Guilford, 1991
Miller WR, Rollnick S: Motivational Interviewing, 3rd Edition. New York, Guilford, 2013
Truax CB, Carkaff RR: Toward Effective Counseling and Psychotherapy. Chicago, IL, Aldine, 1967

Motivational Interviewing—Answer Guide | 339

 C H A P T E R 4 6

Systems of Care,
Wraparound Services, and
Home-Based Services
46.1 Which of the following reflects a guiding principle of a system of care (SOC)?

A. Services should be standardized for all children and families.

B. Services should be developmentally appropriate and quickly engage the high-
est and most intensive possible level of care.
C. To promote autonomy for the youth, caregivers should be limitedly integrated
into the treatment process.
D. Services should be integrated and linked to one another.

The correct response is option D: Services should be integrated and linked to

one another.

Among the guiding principles of an SOC, listed in Table 46–1, are these: services
should be individualized for the child and family (option A is incorrect); services
should be developmentally appropriate and least restrictive (option B is incor-
rect); caregivers should be fully integrated into the planning and treatment pro-
cess (option C is incorrect); and services should be integrated and linked to one
another (option D is correct). In addition, case management should be provided
to coordinate care as needed. Early identification and intervention should be pro-
moted to ameliorate outcomes, and a smooth transition to adult services should
be ensured. The rights of children with emotional disturbances should be pro-
tected and efforts at advocacy promoted. All children with emotional distur-
bances should receive services regardless of race, sex, physical disability, religion,
or other characteristics. (Chapter 46, Systems of Care, Wraparound Services, and
Home-Based Services/Historical Roots: Emergence of SOCs and Wraparound,
pp. 1007–1009; Table 46–2, p. 1009)

341
TABLE 46–1. Systems of care: guiding principles
Children with emotional disturbances should receive services that address their emotional,
social, educational, and physical needs.
Services should be individualized for the child and family.
Services should be developmentally appropriate and least restrictive.
Caregivers should be fully integrated into the planning and treatment process.
Services should be integrated and linked to one another.
Case management should be provided to coordinate care as needed.
Early identification and intervention should be promoted to ameliorate outcomes.
A smooth transition to adult services should be ensured.
The rights of children with emotional disturbances should be protected and efforts at advocacy
promoted.
All children with emotional disturbances should receive services regardless of race, sex,
physical disability, religion, or other characteristics.
Source. Adapted from Stroul 2003.

46.2 Which of the following is a key characteristic of wraparound?

A. The use of a deficit model.

B. An approach that identifies a problem and focuses on ameliorating the problem.
C. The value placed on cultural competence.
D. The co-construction by a physician and case manager of a treatment plan.

The correct response is option C: The value placed on cultural competence.

Three key characteristics of wraparound are 1) strength-based orientation (option

A is incorrect), 2) the value placed on cultural competence (option C is correct),
and 3) integration of the family as an active participant in building a treatment
plan (option D is incorrect). Traditional mental health treatment uses a deficit
model that identifies a problem and focuses on ameliorating the problem (options
A and B are incorrect). A strength-based approach, one that identifies positive
coping mechanisms and resiliency factors, can be especially helpful in engaging
with and helping families who come to receive or are referred to wraparound or
SOC services, as these families have significant needs and are often accustomed
to working from the perspective of failure with multiple, often poorly coordi-
nated, agencies and services. (Chapter 46, Systems of Care, Wraparound Ser-
vices, and Home-Based Services/Wraparound Services, p. 1010)

46.3 What was the intent of the Adoption Assistance and Child Welfare Act of 1980?

A. To strengthen permanency planning for children.

B. To create a national network of community mental health centers.
C. To create funding for family preservation and family support programs.
D. To enable children with special needs to access services without resorting to
the juvenile justice or child protective service systems.

342 | Systems of Care and Wraparound Services—Answer Guide

 The correct response is option A: To strengthen permanency planning for chil-
dren.

The intent of the Adoption Assistance and Child Welfare Act of 1980 (P.L. 96-272)
was to strengthen permanency planning for children (option A is correct). States
were required to make reasonable efforts to prevent removal of youth from their
family or to return them to their family, or, if attempts to have the child remain
with the family are unsuccessful, to accomplish permanency planning within a
reasonable amount of time. The U.S. Congress passed the Mental Retardation Fa-
cilities and Community Mental Health Centers (CMHCs) Construction Act in
1963 in order to create a national network of community mental health centers
(option B is incorrect). In 1993, Congress passed legislation establishing Title IV,
Part B-2, of the Social Security Act, creating funding for family preservation and
family support programs (option C is incorrect). A goal of the Child and Adolescent
Service System Program (CASSP), congressionally funded in 1984, was to enable
children with special needs to access services without resorting to the juvenile jus-
tice or child protective service systems (Lourie 2003) (option D is incorrect).
(Chapter 46, Systems of Care, Wraparound Services, and Home-Based Services/
Historical Roots: Emergence of SOCs and Wraparound, p. 1008; Home-Based
Services, p. 1016)

46.4 Multisystemic therapy (MST) has a robust evidence base for use with which pop-
ulation?

A. Adults with psychiatric problems as a primary concern.

B. Youth with psychiatric problems as a primary concern.
C. Adults at risk for incarceration.
D. Juvenile offenders and substance-abusing youth.

The correct response is option D: Juvenile offenders and substance-abusing youth.

MST is a home-based, family-focused program, meant to treat youth who have se-
rious behavioral problems (options A and C are incorrect). MST has a robust evi-
dence base from randomized clinical trials for use with juvenile offenders and
substance-abusing youth at risk for out-of-home placement (option D is correct).
The evidence for populations with psychiatric problems as a primary concern is
less established (option B is incorrect). (Chapter 46, Systems of Care, Wrap-
around Services, and Home-Based Services/Home-Based Services and Mental
Health, p. 1017)

References
Lourie IS: A history of community child mental health, in The Handbook of Child and Adolescent
Systems of Care: The New Community Psychiatry. Edited by Pumariega AJ, Winters NC. San
Francisco, CA, Jossey-Bass, 2003, pp 1–16
Stroul BA: Systems of care: a framework for children’s mental health care, in The Handbook of
Child and Adolescent Systems of Care: The New Community Psychiatry. Edited by Pumar-
iega AJ, Winters NC. San Francisco, CA, Jossey-Bass, 2003, pp 17–34

Systems of Care and Wraparound Services—Answer Guide | 343

 C H A P T E R 4 7

Milieu Treatment
Inpatient, Partial Hospitalization, and
Residential Programs
47.1 What intervention targets impulsive aggression, noncompliance, and engage-
ment in therapy; is increasingly being employed in milieu therapy programs; and
is especially useful for suicidal and self-injurious youth?

A. Repeated seclusion and restraint.

B. Level systems.
C. Dialectical behavior therapy (DBT).
D. Chemical restraint and as-needed (prn) sedation.

The correct response is option C: Dialectical behavior therapy (DBT).

DBT is increasingly being employed in milieu therapy programs and is especially

useful for suicidal and self-injurious youth by targeting impulsive aggression,
noncompliance, and engagement in therapy (option C is correct). Repeated se-
clusion and restraint, sexualized behavior, and issues concerning safety are all
threats to a program’s integrity as related to licensure and certification (option A
is incorrect). Perceptions vary about interventions that are widely accepted and
employed across milieu therapy programs, such as seclusion and restraint, time-
out, level systems, and as-needed (prn) medications (options B and D are incor-
rect). (Chapter 47, Milieu Treatment/Common Issues/Clinical Issues, pp. 1031–
1032)

47.2 Outcome studies of residential treatment centers suggest that which of the follow-
ing factors is associated with a positive outcome?

A. Exiting at the lowest level of restrictedness.

B. Organic etiology for the psychiatric disorder.
C. Presence of psychosis.
D. Below-average level of intelligence.

The correct response is option A: Exiting at the lowest level of restrictedness.

345
 Youth at 12-month follow-up after discharge from an “integrated residential con-
tinuum of care” exiting at the lowest level of restrictiveness compared with those
at higher levels of restrictiveness had more positive outcomes (i.e., they were
most likely to be living at home or in a homelike setting and experiencing fewer
postdeparture out-of-home placements) but no differences in substance use, ar-
rests, school attendance, or graduation rate (Ringle et al. 2012) (option A is cor-
rect). Outcome studies of residential treatment centers continue to suggest that
factors associated with poor outcomes include presence of psychosis (option C is
incorrect), organic etiology for the psychiatric disorder (option B is incorrect), be-
low-average level of intelligence (option D is incorrect), antisocial and bizarre
behavior, dysfunctional family, insufficient duration of residential treatment to al-
low for consolidation of gains, and adequate aftercare services (Kutash and Rivera
1995). (Chapter 47, Milieu Treatment/Residential Treatment Centers/Outcome
and Quality Assessment, p. 1037)

47.3 What variable is the most consistent, largest predictor of length of stay (LOS) for
youth admitted to an inpatient hospital unit?

A. Suicide risk.
B. Dangerousness to others.
C. Consistency of symptoms across multiple contexts.
D. The hospital itself.

The correct response is option D: The hospital itself.

Nonclinical variables may best predict LOS for youth, contributing between 22%
and 30% to the variance (Case et al. 2007). Leon et al. (2006) reported that the most
consistent, largest LOS predictor was the hospital itself (option D is correct). Clin-
ical predictors accounted for only 7% of variance, with suicide risk predicting
lower LOS (option A is incorrect); longer LOS was predicted by danger to others
and consistency of symptoms across multiple contexts (options B and C are incor-
rect). (Chapter 47, Milieu Treatment/Inpatient Hospitalization, p. 1038)

47.4 Which of the following was a result of a study by Katz et al. (2004) that compared
the outcomes for two groups of suicidal adolescents—one group that received di-
alectical behavior therapy (DBT) administered in 10 daily sessions on one acute
hospital unit and another group that received treatment as usual (TAU, compris-
ing psychodynamically oriented crisis assessment and treatment) on a matched
unit?

A. The DBT group had significantly fewer behavioral incidents during hospital-
ization.
B. The DBT group had a shorter mean LOS.
C. The DBT group demonstrated a significant reduction in suicidality at 1-year
follow-up, whereas the TAU group did not.
D. The TAU group demonstrated a significant reduction in depressive symptoms
at 1-year follow-up, whereas the DBT group did not.

346 | Milieu Treatment—Answer Guide

 The correct response is option A: The DBT group had significantly fewer behav-
ioral incidents during hospitalization.

DBT was equally effective in significantly reducing suicidal ideation, depressive

symptoms, and parasuicidal behavior at 1-year follow-up when administered to
suicidal adolescents in 10 daily sessions on one acute hospital unit compared with
TAU (psychodynamically oriented crisis assessment and treatment) on a matched
unit (options C and D are incorrect). For both groups, mean LOS was 18 days (op-
tion B is incorrect), as-needed medications were employed, and symptom im-
provement was evident at discharge. The DBT group had significantly fewer
behavioral incidents during hospitalization (option A is correct) (Katz et al. 2004).
(Chapter 47, Milieu Treatment/Inpatient Hospitalization/Inpatient Care, p. 1039)

47.5 With what problem do youth most frequently present to acute specialty mental
health inpatient programs?

A. Aggression.
B. Delinquent behavior.
C. Depressed or anxious mood (including self-harm).
D. Suicidality.

The correct response is option C: Depressed or anxious mood (including self-

harm).

Table 47–1 presents the frequency of presenting problems to acute specialty men-
tal health inpatient programs. Among the frequencies are these: depressed or anx-
ious mood (including self-harm), 65% (option C is correct); suicidality, 55%
(option D is incorrect); aggression, 49% (option A is incorrect); and delinquent be-
havior, 25% (option B is incorrect). (Chapter 47, Milieu Treatment/Inpatient Hos-
pitalization/Inpatient Care/Table 47–5, p. 1039)

TABLE 47–1. Frequency of presenting problems to acute specialty mental health

inpatient programs
Problem Frequency

Depressed or anxious mood (including self-harm) 65%

Suicidality 55%
Aggression 49%
Family problems 47%
Alcohol or drug use 26%
Delinquent behavior 25%
Source. Pottick et al. 2004.

Milieu Treatment—Answer Guide | 347

47.6 Outcome studies of partial hospitalization/day treatment programs suggest which
of the following?

A. All children can benefit from this service or be reintegrated into school settings.
B. Individual functioning improves, but family functioning does not.
C. Gains are not generalized to the school setting.
D. Families play noncritical roles posttreatment.

The correct response is option C: Gains are not generalized to the school setting.

Outcome studies of partial hospitalization/day treatment programs suggest the

following: a portion of children can benefit from this service or be reintegrated
into school settings (option A is incorrect), individual and family functioning im-
proves (option B is incorrect), gains are not generalized to the school setting
(option C is correct), and families play critical roles posttreatment as measured
by standardized scales (option D is incorrect) (Grizenko 1997; Kutash and Rivera
1995). (Chapter 47, Milieu Treatment/Partial Hospitalization and Day Treat-
ment/Outcome and Quality Assessment, p. 1042)

References
Case BG, Olfson M, Marcus SC, et al: Trends in the inpatient mental health treatment of children
and adolescents in U.S. community hospitals between 1990 and 2000. Arch Gen Psychiatry
64(1):89–96, 2007 17199058
Grizenko N: Outcome of multimodal day treatment for children with severe behavior problems:
a five-year follow-up. J Am Acad Child Adolesc Psychiatry 36(7):989–997, 1997 9204678
Katz LY, Cox BJ, Gunasekara S, et al: Feasibility of dialectical behavior therapy for suicidal adoles-
cent inpatients. J Am Acad Child Adolesc Psychiatry 43(3):276–282, 2004 15076260
Kutash K, Rivera VR: Effectiveness of children’s mental health services: a review of the literature.
Education and Treatment of Children 18(4):443–477, 1995
Leon SC, Snowden J, Bryant FB, et al: The hospital as predictor of children’s and adolescents’
length of stay. J Am Acad Child Adolesc Psychiatry 45(3):322–328, 2006 16540817
Pottick K, Warner L, Isaacs M, et al: Children and adolescents admitted to specialty mental health
care in the United States, 1986 and 1997, in Mental Health in the United States, 2002. DHHS
Publ No SMA-3938. Edited by Manderscheid RW, Henderson MJ. Rockville, MD, Center for
Mental Health Services, Substance Abuse and Mental Health Services Administration, 2004,
pp 314–326
Ringle JL, Huefner JC, James S, et al: 12-month follow-up outcomes for youth departing and inte-
grated residential continuum of care. Child Youth Serv Rev 34(4):675–679, 2012 24273362

348 | Milieu Treatment—Answer Guide

 C H A P T E R 4 8

School-Based Interventions
48.1 Of the following descriptions of models of school consultation and direct service,
which refers to the case consultation model?

A. In this model, clinicians advise school personnel about appropriate educational

and/or therapeutic approaches to and/or services for individual students with
developmental, cognitive, emotional, behavioral, or social problems.
B. In this model, clinicians are engaged by the school to advise school personnel
about the creation of a milieu that is conducive to learning.
C. In this model, mental health services are delivered in the context of a school-
based health center.
D. In this model, schools are linked with hospitals or community clinics that are
contracted to provide medical and mental health services to students at con-
venient locations off site from the school.

The correct response is option A: In this model, clinicians advise school person-
nel about appropriate educational and/or therapeutic approaches to and/or
services for individual students with developmental, cognitive, emotional, be-
havioral, or social problems.

In the case consultation model, clinicians advise school personnel about appro-
priate educational and/or therapeutic approaches to and/or services for individ-
ual students with developmental, cognitive, emotional, behavioral, or social
problems (option A is correct). In the systems consultation model, clinicians are
engaged by the school to advise school personnel about the creation of a milieu
that is conducive to learning (option B is incorrect). In the school-based health
centers model, a direct service model, mental health services are delivered in the
context of a school-based health center (option C is incorrect). In the school-linked
health centers model, another type of direct service model, schools are linked
with hospitals or community clinics that are contracted to provide medical and
mental health services to students at convenient locations off site from the school
(option D is incorrect). (Chapter 48, School-Based Interventions/Models of
School Consultation and Direct Service, pp. 1050–1052)

349
48.2 Which of the following is a provision in the Individuals With Disabilities Educa-
tion Act (IDEA)?

A. Eligibility of a child for special education services if he or she meets criteria for
one or more categories of disability and if the disability substantially interferes
with his or her educational progress.
B. The creation of a partnership between schools and community agencies and
programs to move toward a full continuum of mental health services.
C. The mandated inclusion without discrimination for any person who has a
“physical or mental impairment that substantially limits a major life activity.”
D. The prohibition of discrimination through its equal protection clause.

The correct response is option A: Eligibility of a child for special education ser-
vices if he or she meets criteria for one or more categories of disability and if the
disability substantially interferes with his or her educational progress.

According to the provisions of IDEA, a child is eligible for special education ser-
vices if he or she meets criteria for one or more categories of disability and if the
disability substantially interferes with his or her educational progress (option A
is correct). Expanded school mental health is a framework that creates a partner-
ship between schools and community agencies and programs to move toward a
full continuum of mental health services (option B is incorrect). Section 504 of the
Rehabilitation Act (P.L. 93-112, 93rd Congress, H.R. 8070, September 26, 1973)
mandates inclusion without discrimination for any person who has a “physical or
mental impairment that substantially limits a major life activity” (option C is in-
correct). The Fourteenth Amendment to the U.S. Constitution prohibits discrimi-
nation through its equal protection clause (option D is incorrect). (Chapter 48,
School-Based Interventions/Models of School Consultation and Direct Ser-
vice/Direct Service/Expanded School Mental Health Programs, p. 1052; Educa-
tional Rights of Students With Mental Disabilities, pp. 1052–1053)

48.3 As required by federal guidelines, within what time period must the school com-
plete the conducted special education evaluation after receiving parental consent?

A. 30 calendar days.
B. 60 calendar days.
C. 90 calendar days.
D. 180 calendar days.

The correct response is option B: 60 calendar days.

Informed consent for the special education evaluation must be sought by the
school from the student’s parents. If the school conducts a special education eval-
uation, it must be completed within a specified time period (the federal guideline
is 60 calendar days after receiving parent consent) (option B is correct; options A,
C, and D are incorrect). If the findings from the special education evaluation indi-
cate that the child has a disability and would benefit from special education, the

350 | School-Based Interventions—Answer Guide

 school-based team will develop a written individualized education program for
the child in collaboration with his or her parents within a specified time period
(the federal guideline is 30 calendar days). (Chapter 48, School-Based Interven-
tions/Educational Rights of Students With Mental Disabilities/Individuals With
Disabilities Education Act, pp. 1055–1056)

48.4 Which of the following describes the Good Behavior Game?

A. It is a classroom-wide, teacher-delivered intervention in which teachers in

early elementary grades model and reinforce student behaviors identified by
the schools as promoting a positive learning environment.
B. It posits that continual behavioral coaching combined with acknowledgment
of positive student behavior will reduce unnecessary disciplinary actions and
promote a climate of greater productivity, safety, and learning.
C. It targeted elementary school students and focused on teacher training, child
skill development, and parent training.
D. It targeted high school students and focused on developing cognitive and in-
terpersonal skills and creating an environment that enhanced connectedness.

The correct response is option A: The Good Behavior Game is a classroom-wide,

teacher-delivered intervention in which teachers in early elementary grades
model and reinforce student behaviors identified by the schools as promoting
a positive learning environment.

The Good Behavior Game is a classroom-wide, teacher-delivered intervention in

which teachers in early elementary grades model and reinforce student behaviors
identified by the schools as promoting a positive learning environment (option A
is correct). School-Wide Positive Behavioral Interventions and Supports posits
that continual behavioral coaching combined with acknowledgment of positive
student behavior will reduce unnecessary disciplinary actions and promote a cli-
mate of greater productivity, safety, and learning (option B is incorrect). The Seat-
tle Social Development Project targeted elementary school students and focused
on teacher training, child skill development, and parent training (option C is in-
correct). The Gatehouse Project targeted high school students and focused on de-
veloping cognitive and interpersonal skills and creating an environment that
enhanced connectedness (option D is incorrect). (Chapter 48, School-Based Inter-
ventions/Interventions in the School Setting/Preventive Interventions/Univer-
sal Preventive Interventions/General Interventions, pp. 1061–1063)

48.5 What are universal preventive interventions?

A. They are intended to prevent the development of symptoms in high-risk stu-

dents and as such are targeted at students exhibiting risk factors for psychiat-
ric disorders.
B. They are intended to prevent the escalation of subsyndromal symptoms of
psychiatric disorders to syndromal disorders and as such are targeted at stu-
dents exhibiting symptoms.

School-Based Interventions—Answer Guide | 351

 C. They are intended to promote mental health and as such are targeted at all stu-
dents, regardless of risk status.
D. They are intended to treat psychiatric disorders and are targeted at students
with psychiatric diagnoses.

The correct response is option C: They are intended to promote mental health
and as such are targeted at all students, regardless of risk status.

Universal preventive interventions are intended to promote mental health and as

such are targeted at all students, regardless of risk status (option C is correct). Se-
lective preventive interventions are intended to prevent the development of symp-
toms in high-risk students and as such are targeted at students exhibiting risk
factors for psychiatric disorders (option A is incorrect). Indicated preventive inter-
ventions are intended to prevent the escalation of subsyndromal symptoms of
psychiatric disorders to syndromal disorders and as such are targeted at students
exhibiting symptoms (option B is incorrect). Clinical interventions are intended to
treat psychiatric disorders and are targeted at students with psychiatric diagnoses
(option D is incorrect). (Chapter 48, School-Based Interventions/Interventions
in the School Setting, p. 1060)

352 | School-Based Interventions—Answer Guide

 C H A P T E R 4 9

Collaborating With
Primary Care
49.1 What was the Triple Aim of the 2010 Affordable Care Act as it related to behavioral
health care?

A. Saving costs, reducing hospital admissions, and forming accountable care or-
ganizations and patient-centered medical homes.
B. Improving coverage of behavioral health treatment, calling for increased pro-
vider accountability to improve access to and the experience of care and qual-
ity of care provided, and doing so at significant cost savings.
C. Expanding collaborative care, integrated care, and child psychiatry access pro-
grams.
D. Mandating that psychiatrists consult with, collaborate with, and teach and
mentor primary care physicians (PCPs).

The correct response is option B: Improving coverage of behavioral health

treatment, calling for increased provider accountability to improve access to
and the experience of care and quality of care provided, and doing so at signif-
icant cost savings.

The Affordable Care Act requires improved coverage of behavioral health treat-
ment, calls for increased provider accountability to improve access to and the ex-
perience of care and quality of care provided, at significant cost savings. The
Institute for Healthcare Improvement has called these three aims of health reform
the Triple Aim (option B is correct). Initiatives are under way that call for im-
proved integration of behavioral health within primary care in response to the de-
mand to improve the coordination of care and the effectiveness of care. A goal is
to achieve cost savings through the reduction of hospital admissions with the for-
mation of accountable care organizations and patient-centered medical homes
(Katon and Unützer 2011; Russell 2010), but this is not the Triple Aim of the Af-
fordable Care Act (option A is incorrect). Over the past decade, population-based
systems, termed child psychiatry access programs, have been developed to provide
a range of collaborative child and adolescent psychiatry services for pediatric pri-
mary care teams in order to enhance the ability of PCPs to address mental health

353
 needs of children and adolescents; however, this is not the Triple Aim of the Af-
fordable Care Act (option C is incorrect). Collaboration, consultation, and teach-
ing are essential skills for the collaborating and consulting child and adolescent
psychiatrist, but these are not the Triple Aim of the Affordable Care Act (option
D is incorrect). (Chapter 49, Collaborating With Primary Care, pp. 1075–1077;
Essential Skills for the Collaborating and Consulting Child and Adolescent
Psychiatrist, pp. 1081–1082)

49.2 How does the cost of care for treating a medical condition change when the indi-
vidual has a co-occurring mental illness or substance use disorder?

A. It decreases by 50%.
B. It decreases at least two to three times.
C. It increases by 50%.
D. It increases at least two to three times.

The correct response is option D: It increases at least two to three times.

The cost of care for treating a medical condition increases at least two to three
times if the individual has a co-occurring mental illness or substance use disorder
(Melek et al. 2014) (option D is correct; options A, B, and C are incorrect). (Chapter
49, Collaborating With Primary Care, p. 1075)

49.3 What is typically meant by the term collaborative care?

A. A team of primary care and behavioral health clinicians, working together with
patients and families.
B. An alliance and partnership between various providers and/or agencies in or-
der to provide effective care coordination across behavioral health and pri-
mary care.
C. Enhancing the availability of child psychiatrists in urban populations.
D. The screening of patients by psychiatrists for signs and symptoms of and risks
for mental health problems.

The correct response is option B: An alliance and partnership between various

providers and/or agencies in order to provide effective care coordination across
behavioral health and primary care.

The terms collaborative care and integrated care are often used interchangeably.
However, collaborative care typically refers to the development of alliances and
partnerships between various providers and/or agencies in order to provide ef-
fective care coordination across behavioral health and primary care (option B is
correct). Integrated care typically involves a team of primary care and behavioral
health clinicians, working together with patients and families (Peek and National
Integration Academy Council 2013) (option A is incorrect). There is great dispar-
ity across the United States in the availability of child psychiatrists, with rural and
poor populations having the greatest shortage and therefore the worst access to

354 | Collaborating With Primary Care—Answer Guide

 care (Thomas and Holzer 2006) (option C is incorrect). An expectation for the role
of primary care in the mental health care of children is that the PCP will screen for
and identify signs and symptoms of and risks for mental health problems (option
D is incorrect). (Chapter 49, Collaborating With Primary Care, pp. 1076–1077)

49.4 What is an expectation for the role of primary care in the mental health care of
children?

A. As part of the care of the well child and routine health maintenance, the pri-
mary care physician (PCP) will provide comprehensive psychiatric treatment
for patients with mental health problems.
B. The PCP will screen for and identify signs and symptoms of and risks for men-
tal health problems.
C. The PCP will defer all monitoring of treatment effectiveness to the psychia-
trist.
D. The PCP always primarily manages the mental health care of the child.

The correct response is option B: The PCP will screen for and identify signs and
symptoms of and risks for mental health problems.

Expectations for the role of primary care in the mental health care of children in-
clude the following: 1) As part of the care of the well child and routine health
maintenance, the PCP will provide anticipatory guidance to promote mental
health and draw attention to early warning signs of mental health problems (op-
tion A is incorrect). 2) The PCP will screen for and identify signs and symptoms
of and risks of mental health problems (option B is correct).... 5) As part of evi-
dence-based mental health treatment protocols, the PCP will be involved in fol-
low-up care and monitoring for treatment effectiveness (symptom change and
improvement in functioning) (option C is incorrect).... 7) The PCP will be part of
a multidisciplinary team providing an integrated approach to the mental health
care of the child (option D is incorrect). (Chapter 49, Collaborating With Primary
Care, p. 1077)

49.5 Providing mental health care in the primary care clinic requires that the pediatri-
cian or family physician do which of the following?

A. Establish local or regional connections with mental health professionals to

participate as team members in the patient’s care.
B. Locate a mental health professional within driving distance from the clinic.
C. Allow providers to use their own screening protocols, triage and referral pro-
cesses, and treatment and monitoring pathways.
D. Minimize connection among psychiatrists, psychologists, social workers, ad-
vanced practice nurses (APNs), and the primary care physician (PCP) to avoid
confusion.

The correct response is option A: Establish local or regional connections with

mental health professionals to participate as team members in the patient’s care.

Collaborating With Primary Care—Answer Guide | 355

 Core principles of collaborative care include: 1) Establish local or regional connec-
tions with mental health professionals to participate as team members in the pa-
tient’s care (option A is correct).... 3) Locate a mental health professional in the
clinic to provide triage assessments, crisis counseling, case management services,
and patient and family education (option B is incorrect). 4) Establish screening
protocols, triage and referral processes, and treatment and monitoring pathways
so that all providers consistently follow similar standards of care (option C is in-
correct). 5) Have continuing education, in either lecture or case discussion format,
to provide ongoing connection among psychiatrists, psychologists, social workers,
APNs, and the PCP (option D is incorrect). (Chapter 49, Collaborating With Pri-
mary Care/Core Principles of Collaborative Care, pp. 1082–1083)

49.6 A 9-year-old patient was diagnosed with attention-deficit/hyperactivity disorder

several years ago; he experienced failed trials of methylphenidate and atomoxe-
tine. He repeated third grade this year, and his school recommends that the stu-
dent again repeat third grade. With his worsening behavior, the school is reluctant
for him to return in the fall. At home, his parents have struggled controlling his
behavior: he is not responding to behavior limitations and is at times rough with
his infant sister. The boy is well medically, and the pediatrician does not feel she
has to see the patient regularly any longer. On the collaborative care spectrum,
what level of care is most ideal for this patient?

A. Primarily primary care.

B. Primarily primary care with consultation.
C. Shared care.
D. Primarily mental health care.

The correct response is option D: Primarily mental health care.

Collaborative mental health care can be considered along a spectrum of five levels:

1. Primarily primary care: The pediatrician or family physician identifies and treats
the child with a less severe psychiatric problem. (Because this patient has been
unresponsive to medications, option A is incorrect.)
2. Primarily primary care with consultation: The primary care physician (PCP) con-
sults with a child psychiatrist or a psychologist regarding approaches to as-
sessment, diagnosis, and treatment. The psychiatrist may be consulted to
inquire about medications: which ones to consider, when to consider them, ap-
propriate dosing and titration, recommended length of treatment, and how to
appropriately monitor. Consultation may occur at any time in the course of
treatment. (Because this patient has failed multiple trials of medication and be-
havior is worsening, option B is incorrect.)
3. Shared care: The PCP identifies, assesses, and then refers for an emergency con-
sultation with a child and adolescent psychiatrist but then shares in the ongoing
care of the patient. Examples here might be a child with depression co-managed
for cognitive-behavioral therapy, a child requiring psychiatry evaluation be-

356 | Collaborating With Primary Care—Answer Guide

 cause of inadequate response to medications, or a child with increased suicidal
risk. (Because this is not an emergency and the child is in need of continued
expert psychiatric care, option C is incorrect.)
4. Shared care and higher levels of care: The patient may require a higher level of
care, such as more frequent follow-up, closer monitoring, and even hospital-
ization, partial hospitalization (day treatment), or intensive outpatient treat-
ment. Additional community support services may be required, such as a
mental health case manager. Responsibility for management of the patient is
shifted to the mental health specialist, but the PCP is still actively involved in
management of physical health.
5. Primarily mental health care: The child and adolescent psychiatrist is the pri-
mary medical provider managing the child’s mental illness because of the
level of severity, the level of complexity of the individual and family problems,
higher levels of concern regarding safety, and/or the coexistence of other compli-
cating conditions. Examples would be children with bipolar disorder, schizophre-
nia, or severe attention-deficit/hyperactivity disorder unresponsive to usual
medications. (option D is correct, because the patient’s behavior is not respon-
sive to typical medication approaches, the pediatrician does not need to follow
the child medically, and the patient and problems with his family are worsening.)
(Chapter 49, Collaborating With Primary Care/Collaborative Care, pp. 1080–
1081)

49.7 How is improved collaboration between primary care physicians (PCPs) and
child/adolescent psychiatrists beneficial for children who require mental health
care?

A. Collaboration increases access to mental health care for children and reduces
cost of providing care.
B. Collaboration decreases communication between PCPs and psychiatrists.
C. Collaboration limits screening of patients for childhood psychiatric diagnoses.
D. Collaboration leads to all children accessing more intensive level of services.

The correct response is option A: Collaboration increases access to mental

health care for children and reduces cost of providing care.

Improved collaboration between PCPs and child and adolescent psychiatrists can
increase access to mental health care for children and reduce 1) the use of more
intensive levels of mental health services and 2) overall cost in providing im-
proved care because of earlier identification and earlier intervention (option A is
correct; option D is incorrect). The PCP who is prescribing psychotropic medica-
tions and is sharing the care of the patient with a therapist must have ongoing
communication with the therapist to ensure optimal coordination of care. Physi-
cians need to communicate to the therapist that ongoing communication is desired
and is expected but also commit to communicating regularly with the therapist (op-
tion B is incorrect). Collaborative child psychiatry consultants may have a critical
role to play in the implementation of an effective screening process in the primary

Collaborating With Primary Care—Answer Guide | 357

 care setting through providing technical support in the selection of appropriate
screening instruments and screening methodology and assisting in the follow-up
assessment of patients with positive screens (option C is incorrect). (Chapter 49,
Collaborating With Primary Care/Components of Collaborative and Consulta-
tive Care in the Primary Care Setting, pp. 1083–1084; Summary Points, p. 1085)

49.8 Which of the following describes the consultative role of child and adolescent
psychiatrists in regard to effective screening?

A. Psychiatrists do not have screening methods or perform interpretations be-

cause paraprofessional staff can do this.
B. Psychiatrists may recommend screening tools without concern for appropri-
ate follow-up strategies and resources.
C. Psychiatrists can provide technical support in the selection of appropriate
screening instruments and screening methodology and assist in the follow-up
assessment of patients with positive screens.
D. Psychiatric consultants should not be involved in choosing screening tools.

The correct response is option C: Psychiatrists can provide technical support in

the selection of appropriate screening instruments and screening methodology
and assist in the follow-up assessment of patients with positive screens.

Collaborative child psychiatry consultants may have a critical role to play in the
implementation of an effective screening process in the primary care setting
through providing technical support in the selection of appropriate screening in-
struments and screening methodology and assisting in the follow-up assessment
of patients with positive screens (option C is correct; option A is incorrect).
Screening without well-planned follow-up strategies and resources results in un-
satisfactory experiences with and lack of maintenance of screening (option B is in-
correct). Although administration of the screening tool is ordinarily performed by
paraprofessional office staff, interpretation and review of the completed screen
with the patient and/or the parent involves clinical sensitivity and expertise (op-
tion A is incorrect). Consultation by a child and adolescent psychiatrist in the plan-
ning of the screening activity and subsequently as needed can facilitate the
development of such competency (option D is incorrect). (Chapter 49, Collaborat-
ing With Primary Care/Components of Collaborative and Consultative Care in
the Primary Care Setting, p. 1083)

References
Katon W, Unützer J: Consultation psychiatry in the medical home and accountable care organiza-
tions: achieving the triple aim. Gen Hosp Psychiatry 33(4):305–310, 2011 21762825
Melek, S, Norris, D, Paulus J: Economic Impact of Integrated Medical-Behavioral Healthcare: Im-
plications for Psychiatry. Prepared for American Psychiatric Association. Denver, CO, Milli-
man, 2014

358 | Collaborating With Primary Care—Answer Guide

Peek CJ, National Integration Academy Council: Lexicon for Behavioral Health and Primary Care
Integration: Concepts and Definitions Developed by Expert Consensus (AHRQ Publication
No. 13-IP001-EF). Rockville, MD, Agency for Healthcare Research and Quality, 2013
Russell L: Mental Health Care Services in Primary Care: Tackling the Issues in the Context of
Health Care Reform. Washington, DC, Center for American Progress, 2010
Thomas CR, Holzer CE III: The continuing shortage of child and adolescent psychiatrists. J Am Acad
Child Adolesc Psychiatry 45(9):1023–1031, 2006 16840879

Collaborating With Primary Care—Answer Guide | 359

 STUDY GUIDE TO

Study Guide to Child and Adolescent Psychiatry is a question-and-answer

Child and Adolescent
PSYCHIATRY
companion that allows you to evaluate your mastery of the subject matter as you progress
through Dulcan’s Textbook of Child and Adolescent Psychiatry, Second Edition. The Study
Guide is made up of approximately 270 questions divided into 49 individual quizzes of 5–8
questions each that correspond to chapters in the textbook. Questions are followed by
an answer guide that references relevant text (including page numbers) in the textbook to
allow quick access to needed information. Each answer is accompanied by a discussion

Child and Adolescent PSYCHIATRY

that not only addresses the correct response but also explains why other responses are
not correct. A Companion to Dulcan’s Textbook of
The Study Guide’s companion, Dulcan’s Textbook of Child and Adolescent Psychiatry, Child and Adolescent Psychiatry, Second Edition
Second Edition, has been thoroughly updated to reflect significant changes to psychiat-
ric nomenclature and criteria in DSM-5. This new edition prunes older content while dis-

STUDY GUIDE TO
tilling and incorporating clinically relevant findings. Reorganized chapters feature tables
of selected diagnostic criteria from DSM-5 for quick reference.

Philip R. Muskin, M.D., M.A., is Professor of Psychiatry at CUMC, Consul-

tation-Liaison Psychiatry at Columbia University Medical Center; and faculty
member at the Columbia University Psychoanalytic Center.

Anna L. Dickerman, M.D, is Assistant Professor of Clinical Psychiatry at Weill

Cornell Medical College and Assistant Attending Psychiatrist at NewYork-Pres-
byterian Hospital.

Oliver M. Stroeh, M.D., is Clarice Kestenbaum, M.D. Assistant Professor of

Education and Training in the Division of Child & Adolescent Psychiatry (in
Psychiatry) at CUMC, Columbia University College of Physicians & Surgeons;
NewYork-Presbyterian Hospital; New York State Psychiatric Institute.

Dickerman
Muskin
Stroeh

9000 0

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