ABP Content Specs #4: Assessment and Management Flashcards
1
Q
Developmental surveillance includes?
A
-should occur at all well child visits from birth through age 5 years
-helps HCP identify children who may have developmental problems
2
Q
6 components of developmental surveillance?
A
- eliciting and attending to parents’ concerns about development
- obtain, document, and maintain a developmental history
- making accurate and informed observations of child
- identifying risks, strenghts, and protective factors
- maintaining an accurate record of the process and findings
- sharing and obtaining opinions and findings with other professionals
3
Q
Developmental screening?
A
-use of validated screening tool to further identify developmental concerns
-meant to identify children whose development differs from same-aged norms and does not result in a diagnosis
-should use a validated tool at 9, 18, 30 month visits with ASD-specific screening at 18 and 24 months
4
Q
What makes up good screening test?
A
- reliable (able to produce consistent results)
- Valid (able to discriminate between a child at a determined level of risk for delay from the rest of the population)
- Good sensitivity (accuracy in identifying delayed development) to minimize under-referrals (>70%)
- Good specificity (accuracy in identifying children who are NOT delayed) to minimize over-referrals (>70%)
- standardized based on a large, representative national sample
- Current (should re-standardize norms every 10 years)
- PPV range of 30-50% typical
- feasible: low cost, reasonable time burden for parent and clinical staff, readability <5th grade level
- culturally and linguistically appropriate
5
Q
Developmental assessment?
A
a skilled person evaluates development to make a diagnosis of developmental disorder or delay
6
Q
Newborn hearing screen criteria?
A
- all infants screened by 1 month of age
- comprehensive eval by 3 months of age for those that didn’t pass NBS
- appropriate intervention by 6 months if confirmed hearing loss
- infants admitted to NICU for >5 days should have ABR as part of screening to avoid missing SNHL
- for re-screening, complete screening on both ears even if only 1 ear failed initial screen
- repeat hearing screen after readmission in 1st month of life for infants with conditions like hyperbilirubinemia, culture-positive sepsis
7
Q
How to screen for newborn hearing?
A
- OAE only (may miss SNHL)
- ABR only
- 2 step: combined OAE and ABR; decreased failure rate at discharge
8
Q
Oto-acoustic emissions (OAE)?
A
-used 0-6 months of age
-measurement of normally produced sound responses generated by hair cells in cochlea
-measured by placing small probe w/ soft rubber tip in ear and providing sound stimulation
-presence of OAE indicates MIDDLE and INNER ear functioning appropriately
Limitations: doens’t give info about degree/severity of hearing loss & may not detect minimal/slight hearing loss or SNHLAudit
9
Q
Auditory evoked response (ABR)?
A
-measures auditory nerve’s response to sound
-3-4 electrodes placed on child’s head near the ears –> provide stimuli (clicks) through headphones –> presence or absence of waveforms at specific sound levels and frequencies can confirm/describe hearing loss
-child must be completely still –> requires sedation ages 6 month to 7 years
10
Q
Behavioral audiometry?
A
-sounds played and chlid’s response monitored and recorded
11
Q
Types of Behavioral audiometry?
A
- Behavioral observation audiometry (0-5 months); audiologist observes/records responses to sounds (e.g. quieting, eye widening, startle)
- Visual reinforcement audiometry (6 mo-2 years):
observes and records when child turns to sound stimulus and gives a visual reinforcement or reward that is timed to the response (toy or puppet lights up/moves) - Conditioned Orientation Reflex: same as VRA but includes more than 1 sound source and puppet reinforce used; i.e. one on left and one on right
- Conditioned play audiometry: 2-5 years
-audiologist establishes a “listening game” by using toys to maintain the child’s attention and focus on the listening task (ie. drop a block in bucket when sound is heard) - Conventional audiometry (>5 year): child raises hand or provides a verbal response to presentation of various sounds
- Soundfield audiometry: sounds presented via speakers rather than headphones (used when child cannot tolerate headphones); cannot test ears separately (results reflect hearing in stronger ear)
12
Q
Cranium dysmorphology:
Brachy-cephaly
A
shortened antero-posterior length of the head compared to width
13
Q
Cranium dysmorphology:
Dolicho-cephaly
A
increased antero-posterior length of head compared to width
14
Q
Cranium dysmorphology:
Trigono-cephaly
A
wedge-shaped head (apex of triangle at midline of the forehead)
15
Q
Cranium dysmorphology:
Turri-cephaly
A
tall head relative to width and length
16
Q
Frontal bossing?
A
bilateral bulging of the lateral frontal bone prominences with relative sparing of the midline
17
Q
Prominent glabella?
A
forward protrusion of the forehead in midline between supra-orbital ridges
18
Q
Midface retrusion?
A
posterior positioning and/or vertical shortening of the infra-orbital and peri-alar regions or increased concavity of he face and/or reduced nasolabial angle
19
Q
Retrognathia
A
posterior positioned lower jaw
20
Q
Micrognathia
A
apparently reduced length and width of the jaw when viewed from the front
21
Q
Epicanthal fold?
A
fold of skin starting above the medial aspect of the upper eyelid and arching downward to cover, pass in front of and lateral to the medial canthus
22
Q
Hypertelorism
A
widely spaced eyes
23
Q
Hypotelorism
A
closely spaced eyes
24
Q
synophyrs
A
meeting of the medial eyebrows in the midline
25
Clinodactyly
digit that is laterally curved in the plane of the palm
26
cutaneous syndactyly
soft tissue continuity in the A/P axis between two fingers that extends distally to at least the level of the PIPJ
27
postaxial polydactyly
presence of super-numarary digit that is not a thumb/great toe
28
10 ACES? adverse childhood experiences
physical abuse
verbal abuse
sexual abuse
physical neglect
emotional neglect
parent who's an alcoholic
mother who's victim of CV
family member in jail
family member w/ mental illness
disappearance of parent through divorce/death/abandonment
29
Phonology?
sound system of language
30
Phonological awareness
metalinguistic awareness of all levels of speech sound system including word boundaries, stress syllables, phonemes
31
Semantics
meaning of language, vocabulary and word relationships
32
Morphology
understanding of morphemes - smallest units of language that have meaning
33
Syntax
structure, sentence structure, grammar
34
Pragmatics
rules and conventions for using language, gestures in social contexts including discourse-level language skills (conversation, narrative, expository)
35
FISH (fluorescence in situ hybridization) testing indications?
to test for velo-cardiofacial syndrome, if unknown etiology of GDD/ID and unable to do microarray
36
Indications for nerve conduction studies?
acute nerve injury, chronic nerve disorders, detect neuropathic disorders in individuals who have hereditary risk prior to sx, identify unaffected nerves to distinguish a mono-neuropathy from a poly-neuropathy, follow progression of neuropathic condition
37
3 types of breath-holding spells?
1. cyanotic
2. pallid
3. mixed
if pallid then increased risk for vasovasal syncope later in life
38
What helps with treatment of breath holding spells?
iron supplementation 5 mg/kg/day
b/c anemia might increase frequency of BHS
39
Treatment of breath holding spells?
1. reassure that it doesn't harm child
2. if child loses consciousness he starts breathing at that time
3. no need to restrict activities or avoid anger/fear since this will lead to difficulty limit setting later on (child may lead to trigger BHS during tantrums to get to desired response from parent)
40
Periods of crying during infancy?
-fussiness begins at 2 weeks of age, peaks in 1nd and 2nd month and disappears by 3-4 months
-worse in late afternoon and resolves early evening
-infant colic: periods longer or more intense; total more than 3 hours/day on more than 3 days/week of crying
41
What is Bowen Family Systems Theory?
-theory of human behavior that views family as an emotional unit & uses systems thinking to describe the complex interactions in the unit
-it is nature of a family that its members are intensely connected emotionally
-2 main variables in Bowen Theory:
1) degree of anxiety
2) degree of integration of self
42
What is cognitive restructuring?
i.e. cognitive reframing
-from cognitive behavioral therapy that can help ppl identify, challenge, and alter stress-inducing thought patterns and beliefs
43
Dialectical behavior therapy (DBT)?
-combination of individual psychotherapy & group skills training classes to help kids learn and use new strategies to improve their emotional functioning
-skills learned include: mindfulness, emotional regulation, distress tolerance, and interpersonal effectiveness
-offshoot of CBT
-helpful for borderline personality disorder
44
What is process group therapy?
-groups help kids work through psycho-social stressors in safe, supportive environment
-grief groups, social groups to work through bullying, eating disorders group, play therapy groups, etc.
-tool to help kids learn how to trust others, how to share experiences that might otherwise keep bottled up, how to provide and accept supportive feedback to and from peers
45
Treatment of OCD?
-CBT is comprised of 5 phases:
1. psycho-education
2. cognitive training
3. mapping OCD
4. graded exposure and response prevention (ERP)
5. relapse prevention and generalization training
46
In classical conditioning, what is reinforcement?
Reinforcement occurs when the relationship between the conditioned stimulus (e.g. darkness) and the unconditioned response (e.g. fear) becomes strengthened through repeated association
47
In classical conditioning, what is extinction?
occurs when relationship is weakened such that the stimulus no longer elicits the repsonse (e.g. repeatedly going to school without ridicule, forming friends or taking test/submitting assignment with passing score, etc), in which the case the conditioned response is likely to disappear or become extinguished.
48
What is positive reinforcement?
When a behavior is followed by some sort of reward (verbal praise, piece of candy), the behavior is more likely to be repeated.
49
For behavior management, what is interval schedule?
Interval schedules involve reinforcing a behavior AFTER a period of time has passed.
50
For behavior management, what is fixed schedule?
In a fixed schedule, the number of responses or amount of time between reinforcements is set and unchanging. Schedule is predictable.
Fixed interval: in operant conditioning, a fixed interval schedule is when reinforcement is given to a desired response after specific/predictable amount of time has passed.
An example: teacher giving students a weekly quiz every Monday. Over the weekend, there is a flurry of studying for the quiz. On monday, the students take the quiz and are reinforced for studying (positive reinforcement: receive a good grade; negative: do not fail the quiz). For next few days, there are likely to relax after finishing the stressful experience until the next quiz date draws too near for them to ignore.
51
What is variable schedule?
in variable schedule, the number of responses and amount of time between reinforcements change randomly. The schedule is unpredictable.
Variable interval: in operant conditioning, a variable interval schedule is when the reinforcement is provided after a random/unpredictable amount of time has passed and following a specific behavior being performed.
52
What is ratio schedule?
in ratio schedule, reinforcement occurs after a certain number of responses have been emitted.
Fixed ratio: in operant conditioning, a fixed-ratio schedule reinforces behavior after a specified number of correct responses. A variable ratio schedule is a schedule of reinforcement where a behavior is reinforced after a random number of responses.
Ex: would be a child being given a candy for every 3-10 pages of a book they read. They are given a candy after reading 5 pages, the n3 pages, then 7 pages, and then 8 pages, etc. THe unpredictable reinforcement motivates them to keep reading, even if they are not immediately reinforced after reading one page.W
53
What is variable ratio?
A variable ratio schedule is a schedule of reinforcement where a behavior is reinforced after a random number of responses.
Results in high. steady rates of responding. Subjects are persistent in responding b/c of hope that the next responses might be one needed to receive reinforcement. Schedule is like lottery games.
54
Extinction burst?
Will see an increase in negative behavior initially after extinction procedures are implemented; need to keep administering therapy to maintain consistency and continue w/ the procedure regardless of the child's reaction
55
Spontaneous recovery?
extinction burst happens after a long period during which the child does NOT engage in problem behavior
56
3 types of extinction procedures?
1. Extinction with behaviors maintained by positive reinforcement
2. Extinction on behaviors maintained by negative reinforcement (escape extinction)
3. Extinction on behavior maintains by automatic reinforcement (sensory extinction)
57
Extinction with behaviors maintained by positive reinforcement?
ex. Danny tries to get mom's attention by dropping toy on floor.
Mom smiles at baby and picks up toy to hand to baby.
This reinforce's baby's negative behavior b/c getting attention that she's seeing so she'll continue the behavior to get the positive reinforcement from mom.
TO solve this, baby's mom should ignore baby when she drops the toy. If she consistently ignores this behavior, it is likely that baby will reduce engaging in this behavior as her actions no longer produce the effect that she is seeking.
58
Extinction on behaviors maintained by negative reinforcement (escape extinction)?
Ex. baby throws tantrum when she doesn't want to eat food. Mom responds by sending her to time out.
Baby is able to avoid food that she doesn't want to eat so she'll continue to tantrum so she can get sent to time out.
To correct, mom should let baby continue the tantrum and not do time out adn then make her eat the food. Initially tantrums will increase but eventually the tantrums will decrease as long as actions do not provide desired outcome.
59
Extinction on behaviors maintained by automatic reinforcement (sensory extinction)?
ex. Baby likes to turn the light switch on and off b/c she is visually stimulated by fans starting and stopping.
To deal, mom should unhook the fan so it won't work when baby turns on light switch. Over time, baby will decrease engaging in this behavior of flipping the light b/c it no longer provides the automatic reinforcement she is seeking.
60
Drug clearance = elimination of drugs from the body = creatinine clearance
clearance = dose/AUC (equation 1) or clearance = infusion rate/C5s (equation 2)
61
AUC = area under curve
represents the total drug exposure integrated over time and is improtant parameter for both pharmacokinetic and pharmacodynamic analyses
The higher the AUC for a given dose, the lower the clearance
62
Cytochrome p450 enzymes
-involved in phase I metabolism which is affected by a series of hepatic enzymes known as cytochrome P450 (CYP) isozymes
-drugs may be substrates, inhibitors, or inducers of one or more p450 enzymes
63
Substrates of metabolism?
a substrate is something that is changed by an enzyme
-many antidepressants, anxiolytics, hypnotics, and antipsychotics are substrates of CYP2D6 and CYP3A4
64
Inhibitors of metabolism?
interferes with ability of an enzyme to affect metabolism, slowing the breakdown of co-prescribed drugs and thus potentially increasing plasma levels
-paroxetine and fluoxetine are strong inhibitors of CYP2D6
-duoloxetine can also act as moderately potent CYP2D6 inhibitor
-fluoxetine inhibitors CYP3A4 and fluovoxamine inhibits CYP1A2
65
Inducers of metabolism?
inducer speeds up enzyme activity usually by causing the synthesis of greater amounts of enzyme so any co-prescribed drug metabolized by the same CYP enzyme will be broken down more rapidly
-carbamazepine, an anti-epileptic drug with mood-stabilizing properties is prescribed by antipsychotic agents when treating bipolar affective disorder
-St John's Wort has CYP3A4-inducing effects and compromise oral contraceptive efficacy
66
What drug is excreted only by kidneys?
lithium
-ACE inhibitors, angiotensin-II antagonists and NSAIDS may also raise plasma lithium by interfering with excretion
-reduced renal function or co-prescription of diuretics (thiazides) will induce sodium deficiency can reduce lithium excretion significantly and cause toxicity
67
How does methylphenidate work?
-increases brain dopamine and NE levels by blocking pre-synaptic reuptake transporters
-inhibits the DA nad NE transporters so it increases DA and NE levels in the brain
68
Other than ADHD, what other condition can be treated with short-acting stimulant med?
narcolepsy and daytime sleepiness
69
First line SSRI for acute depression in pediatric patients?
fluoxetine
then consider sertraline, escitalopram or citalopram, then velafaxine
70
Which SSRI has long half-life?
fluoxetine
71
What are mood stabilizers?
carbamazepine, oxcarbazepine, divalproex, lamotrigine
anticonvulsants used as mood stabilizers? - valproate, gabapentin, lamotrigine, oxcarbazepine
72
Indications for atypical antipsychotics in autism?
irritability (aggression, deliberate self-injurious behaviors, temper tantrums)
Risperidone and Aripiprazole are the only psychotropic medications approved by FDA for treatment of ASD.
73
Other indications for atypical antipsychotics?
Bipolar I (acute manic or mixed episodes)
Disruptive behavior disorders (conduct disorder, ODD, aggression)
Schizophrenia
Tourette syndrome
ADHD (listed as labeled indication for Abilify)
74
Other atypical antipsychotics?
risperidone, abilify, olanzapine, clozapine, quetiapine, ziprasidone
75
Side effects of antipsychotic medications?
1. increased appetite
2. weight gain
3. elevate blood sugar 2/2 insulin resistance
4. dyslipidemia
5. blood pressure changes
6. EKG changes, prolonged QTc (w/ ziprasidone)
7. fatigue, drowsy
8. dizzy
9. drooling
10. LFT abnormal
11. increase in prolactin
12. gynecomastia
13. less common but serious: dystonic reactions, tardive dyskinesia, akathisia (subjective restlessness with voluntary movements of limbs or trunk), neuroleptic malignant syndrome, agranulocytosis (with clozapine)
76
Monitoring for antipsychotics?
1. baseline weight and height, BMI
2. ask about obesity, diabetes, dyslipidemia, hypertension, cardiovascular disease
3. baseline EKG and again at steady state ziprasidone
4. BPs
5. extrapyramidal findings (using abnormal involuntary movement scale)
77
Labs for antipsychotics?
fasting plasma glucose, fasting lipids, CBC, LFT, thyroid stimulating hormone (TSH), prolactin, electrolytes
-f/u at 3 months after start medication, every 6 months
78
Indications for tricylic antidepressants (TCA)?
they inhibit reuptake of norepinephrine and serotonin
1. MDD: rarely used b/c lack of efficacy, unfavorable side effects, high lethality overdose; use if not responsive to anything else
2. Anxiety d/o: not 1st or 2nd line
3. chronic pain management
4. migraine prophylaxis (amitriptyline)
5. OCD (clomipramine)
6. ADHD (imipramine, nortriptyline)
7. enuresis (imipramine, nortriptyline)
8. neuropathic pain
9. insomnia (most TCAs are sedating like amitripytyline, doxepine, trimipramine)
79
Side effects of TCAs?
-has dose-related effects
-tricyclics block muscarinic M1, histamine H1, and alpha-adrenergic receptors
-common: cardiac effects (orthostatic hypotension, prolonged QTc), anticholinergic effects (blurred vision, constipation, dry mouth, urinary retention), antihistamine effects (increase appetite/weight gain, confusion, delirium), decreased seizure threshold, sex dysfunction, diaphoresis, tremor, lower seizure threshold
-dangerous in overdose
80
Side effects of alpha-agonists (clonidine, guanfacine) in sleep
hypotension, anticholinergic, irritability, dysphoria, rebound HTN, parasomnias, develop tolerance
81
How does clonidine work?
-central alpha-adrenergic agonist that decreases adrenergic tone
-onset of action within 1 hour, peak effect 2-4 hours
-tolerance develops, usually necessitates dose increase
82
Side effect of clonidine?
sedation, depression, bradycardia, HA, possible hypotension
-should do tapering of clonidine to prevent rebound BP
-taper guanfacine by <1 mg every 3-7 days to prevent rebound increase in BP; monitor BP and HR during tapering
-adverse effects: HA, fatigue, abdominal pain, constipation, sedation
83
What are the SNRIs?
venlafaxine
duloxetine
84
What are the TCAs?
imipramine, clomipramine
85
What are the benzos?
clonazepam, lorazepam
-effects: drowsiness, irritability and oppositional behavior, subject to abuse and diversion
86
Side effects of bupriopion (atypical antidepressant)?
Dry mouth, nausea, insomnia, dizziness, anxiety, dyspepsia, sinusitis, tremor, weight loss, risk for seizures
*contraindicated in anorexia and bulimia pts b/c of increase risk of seizures
87
Effects on pharmacokinetics ex?
genetic variant that alters drug metabolism, affecting plasma concentration
88
Effects on pharmacodynamics ex?
genetic variation that reduces binding of the drug to its receptor, thus decreasing therapeutic efficacy
89
What is syntax?
sentence structure and grammar rules; how you organize words so that they make the most sense
90
What is semantics?
study of meaning of sentences
91
