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Q1: Distinguishing CD from ODD (2 min)
"How do you distinguish conduct disorder from oppositional defiant disorder, and why does the distinction matter?"
The pivot is whether the behaviour violates the rights of others or major age-appropriate norms. CD involves aggression to people/animals, destruction of property, deceit/theft and serious rule violation. ODD involves angry/irritable mood, argumentative/defiant behaviour and vindictiveness — but no aggression, no property destruction, no theft/deceit, no serious rule violation. The distinction matters for prognosis (CD, especially childhood-onset, may progress to ASPD; ODD often remits or progresses to CD in about 30 percent) and for treatment intensity (MST for severe CD). ODD requires at least 4 symptoms for 6 months; CD requires at least 3 of 15 criteria in 12 months with at least 1 in 6 months.
Q2: Enuresis management (3 min)
"A 7-year-old boy wets the bed nightly. Outline your assessment and the treatment ladder."
First, exclude organic causes: take a history (primary vs secondary; mono- vs non-monosymptomatic), examine (abdomen, spine, neurological), and do a urinalysis to rule out UTI and diabetes mellitus. A voiding/fluid diary documents nocturnal volume. Renal/bladder ultrasound only if recurrent UTI, abnormal stream or day-time symptoms; spinal imaging only if neurological signs.
Treatment ladder:
- Reassurance and general measures — enuresis is common (15 to 20 percent of 5-year-olds) and resolves spontaneously in about 15 percent per year; avoid blame and punishment; regular daytime fluids, limit evening fluids, toileting before bed, star charts rewarding the behaviour of getting up to void.
- First-line specific: the enuresis alarm (body-worn or bed-mat) — 60 to 70 percent success in a motivated family over a minimum 6 to 8 week trial; lower relapse rate than desmopressin.
- Desmopressin (synthetic AVP analogue, 200 to 400 micrograms orally at bedtime) — rapid effect, useful short-term (sleepovers); high relapse on stopping; restrict evening fluids to avoid hyponatraemia.
- Oxybutynin added for day-time symptoms/detrusor overactivity. Imipramine rarely now (cardiotoxicity in overdose).
The mechanism of enuresis combines failure of arousal from sleep, an inadequate nocturnal AVP surge causing nocturnal polyuria, and reduced functional bladder capacity. It is strongly genetic — 44 percent if one parent, 77 percent if both parents were enuretic.
Q3: Safeguarding (2 min)
"You are assessing a child with new behavioural problems and notice unexplained bruises. What are your responsibilities?"
Safeguarding is every doctor's responsibility. The child's safety is paramount. I would: (1) take a careful, trauma-informed history and document the injuries and the explanation verbatim in the child's words; (2) examine fully for other injuries (patterned bruises, injuries of different ages, perineal injury); (3) not interrogate the child or investigate single-handedly; (4) refer immediately to the safeguarding lead and children's social care (and police where there is immediate risk); (5) preserve any forensic evidence. The doctor's duty is to refer and protect, not to confirm the diagnosis. I would follow my local child-protection procedures and the Children Act.
Q4: Selective mutism versus autism (2 min)
"A teacher reports a 6-year-old girl who has never spoken at school in 3 months. How do you distinguish selective mutism from autism, and what is the management?"
The key is whether the child speaks normally in other settings. In selective mutism the child speaks fluently at home (confirmed by history and observation across settings) and has no pervasive social-communication deficit or restricted/repetitive behaviours — she is mute only in specific feared social situations (school), communicating by nodding or gesture. In autism, the social-communication deficit and restricted/repetitive behaviours are pervasive across all settings. I would arrange a hearing assessment and speech-language evaluation, and observe the child at home and at school.
Management of selective mutism: behavioural intervention (stimulus fading, shaping, positive reinforcement for speech, removal of pressure to speak), CBT adapted for age, and family and school involvement (the school must be part of the exposure plan and must not reinforce the mutism by accepting only gestures). An SSRI (e.g. fluoxetine) is added in severe, treatment-resistant cases under specialist supervision. Early treatment gives the best outcome; untreated selective mutism often evolves into social anxiety disorder.
Q5: Principle of child psychiatry (1 min)
"In one sentence, state the overriding principle of pharmacological treatment in child psychiatry and give one reason."
Psychological and behavioural interventions are first-line, and medication is a last resort — because the developing brain is highly plastic (so environmental and behavioural change is both effective and safer), because most childhood disorders are maintained by the family and school environment, and because psychotropic medications carry developmental, metabolic and emergent-suicidality risks that must be weighed against more effective, lower-risk alternatives.