Adolescent and psych Flashcards
Early adolescence vs. middle adolescence vs. late adolescence
Early: 12-14 yrs, preoccupation with changing body
Middle: 15-16 yrs, peak of conflict
Late: 17-19+, future oriented, begin to perceive consequences
Anorexia nervosa
DSM 5 criteria simplified (A,B,C)
A. low body weight secondary to nutritional restriction
B. fear of gaining weight
C. distortion of body image
Bulimia nervosa DSM 5 simplified
- binge eating and purging at least once weekly x 3 months
- body weight is normal or increased
- self evaluation closely linked to body image
Refeeding syndrome risk factors
- rapid wt loss
- extremely low body wt (<70%)
- low baseline phosphate, potassium, magnesium
- little or no intake for 5-10 days prior to refeeding
Criteria for inpatient hospitalization in anorexia nervosa
- <= 75% median BMI for age and sex
- dehydration
- electrolyte disturbance
- EKG abnormality
- unstable:
- bradycardia < 45 bpm onvernight, <50 awake
- hypotension <90/45
- hypothermia <35.6
- orthostatic decrease in BP > 20 SBP, >10DBP - failure of outpatient
etc
Relative energy deficiency in sport (RED-S) Triad
- oligomenorrhea/amenorrhea
- low bone mineral density
- low energy availability
CRAFFT substance use disorder`
- driven in a car
- use to relax
- use while alone
- forget about things you did
- family or friends
- trouble
Cannabis physiologic signs
- tachycardia
- hypertension
- conjunctival injection
- dry mouth
- increased appetite
Cannabis withdrawal signs
- irritability, anger, aggression
- anxiety, nervousness
- sleep difficulty
- restlessness
- depressed mood
- somatic sx causing significant discomfort
Investigations non-amenorrhea abnormal uterine bleeding
- hx and physical
- CBC + ferritin
depending on picture: - pregnancy test
- coags
- thyroid screen
- PCOS investigations
- STI investigations
DDX non-amenorrhea abN uterine bleeding teens
- physiologic adolescent anovulation
- contraception
- infection
- pregnancy related
- bleeding disorder
- PCOS
- thyroid
Heavy menstrual bleeding management (non-acute)
- treat anemia if present
- Hormonal: combined OCP, progestin only or IUD
- non-hormonal: NSAID, TXA
Risks of estrogen containing contraception
- irregular bleeding
- breast tenderness
- nausea
- headaches
- venous thromboembolism 2-4x increased risk
- stroke 1.5-2x increased risk
ABSOLUTE contraindications to estrogen
- < 6 weeks postpartum
- hypertension > 160/100
- current or past hx of VTE or cerebrovascular accident
- migraine with focal neuro sx
- breast cancer (current)
- severe cirrhosis
- liver tumor
- SLE with positive or unknonw antiphospholipid antibody
- complivated valvular heart disease
Contraindications to intrauterine contraception
- pregnancy
- purulent cervicitis
- distortion of uterine cavity
- pelvic TB
- abnormal uterine bleeding that has not been adequately evaluated
- Wilson disease (copper IUD)
Emergency contraception (order of effectiveness)
- copper IUD (up to 7 days post)
- ullipristal acetate (up to 5 days post)
- levonorgestresl (plan B)
- Yuzpe method
Reportable STIs
- chlamydia
- gonorrhea
- syphilis
- HIV
Not reportable: trichomonas, HSV, HPV
Chlamydia tx
Treat with azithro 1g PO once or doxycycline x 7 d
resistance does not exist!
Gonorrhea tx
cefixime + azithro
CTX + azithro
(Combo for resistnace and synergy)
“strawberry cervix” and treatment
Trichomonas vaginalis
Tx: metronidazole
Indication for hospitalization with PID
- severe clinical illness
- tuboovarian abscess
- alternative dx needs to be ruled out
- pregnancy
- inability to tolerate oral meds
- lack of response to oral meds
- concern for nonadherence
Tx PID
cefoxitin + doxycycline
Complications PID
- abscess
- chronic pelvic pain
- ectopic pregnancy
- infertility
Transition of youth principles
- adolescent involved in management of condition
- adolescent understanding the condition
- understanding personal potential for activity, recreation, education, vocation
- completion of adolescent developmental tasks
- attainment of self-esteem and self-confidence
Age of consent sexual activity
- 11yrs and below: canNOT consent
- 12+13 yrs - 2yr close age exception
- 14+15 - 5 yr close age exception
- 16+ can consent to anyone but not in a position of trust/authority
Elements of informed consent
- appropriate information
- capacity
- voluntariness
When to break confidentiality
- risk of serious harm to self
- risk of serious harm to others
- abuse of any child under the age protected by child welfare agency
- reportable illnesses
ADHD medication algorithm
- stimulant (try methylphenidate and at least one amphetamine before moving on)
- a atomoxetine
- b alpha-2 agonists (guanfacine, clonidine) (usually as adjunct)
Stimulants response
- 70% respond to any given stimulant
- 85-90% will respond to metyhylphenidate OR amphetamine
Atomoxetine (straterra) side effects
- sedation
- GI upset
- other: sleep, mood sx, dizziness, increase in HR/BP, dry mouth, constipation, urinary sx, dysmenorrhea, sexual dysfunction, small increase in psychotic sx, suicide-related events, rare cases of severe liver, priapism, sudden death
Adverse effects of alpha-2 agonists e.g. Intuniv
- sedation
- bradycardia
- hypotension
other: dizziness, dry mouth, rebound tachy and HTN, HA, emotional, GI sx, modest increase in QT (guanfacine), ecg abN, suicide
ODD diagnosis
Characterized by sx in domains of: 1. angry/irritable mood 2. argumentative/defiant 3. vindictiveness (do not need all domains)
Conduct disorder diagnosis
Characterized by sx in domains of: 1. aggression 2. destruction of property 3. deceitfulness or theft 4. serious violations of rules (do not need all domains)
Treatment approaches for ODD/CD
- psychoeducation and support (for all)
- psychoscial intervention (for all) e.g. parent management training etc.
- medication (for some)
- to treat ADHD, anxiety/mood sx
- cautious use of antipsychotics for aggression
Antipsychotic adverse effects
- wt gain
- tardive dyskinesia
- acute EPS
- diabetes
- hyperlipidemia
- neutropenia
- orthostasis
- hyperprolactinemia
- increased QTc interval
- sedation
- seizures
Treatment approach for anxiety
- psychoeducation and support (for all)
- psychotherapy (for most)
- primarily CBT - medication (for some)
- primarily SSRI
OCD features
Presence of obsessions and/or compulsions that are:
- time consuming (>1hr/day) or
- cause clinically significant distress or impairment
Treatment approach for OCD
- psychoeducation and support (for all)
- psychotherapy (for most)
- CBT with emphasis on exposure and response prevention (ERP) - medication (for some)
- SSRIs
- clomipramine and augmentation with an antipsychotic in refractory cases
A child with depression
RFs for bipolar disorder
- depressive episode that is rapid onset, psychomotor retardation, psychotic features
- family hx of bipolar disorder
- hx of mania/hypomania after antidepressant treatment
RFs for suicide
- older age
- male sex
- MDD or other psychopathology
- hx of suicde attempts
- presence of suicdial plan/intent
- stressful life events
- exposure to abuse/violence
- access to lethal means
- family history
Treatment approaches for depression
- risk assessment and safety planning (for all)
- psychoeducation and support (for all)
- psychotherapy (for most)
- CBT and interpersonal therapy for adolescents - Medication (for some)
- SSRIs most evidence for fluoxetine
SSRI adverse effects
- GI upset
- headaches
- dizziness
- activation (esp in younger children)
irritability, insomnia/somnolence, appetite change, akathisia, diaphoresis, sexual dysfunction, hyperprolactin, manic sx in predisposed pts, serotonin syndrome, flu like sx during discontinuation
SSRIs with QT prolonagation
- citalopram
- escitalopram
Symptoms of hypophosphatemia
- weakness
- rhabdomyolysis
- neutrophil dysfunction
- cardioresp failure
- arrhythmias
- seizures
- altered LOC
- sudden death
Duration of sx:
- MDE
- PTSD
- GAD
- ODD
- CD
- brief psychotic d/o
- schizoprheniform
- schizophrenia
MDE: 2 weeks PTSD: 1 month GAD: 6 months ODD: 6 months Conduct disorder: 12 months Brief psychotic disorder < 1 mo Schizophreniform < 6 mo Schizophrenia > 6 mo
Developmentally normal separation anxiety
Developmentally normal when it begins at about 10 months of age and taper off by 18 months
By 3 yrs, most children can accept temporary absence of primary caregiver
ADHD comorbidities
- ODD + CD
- anxiety disorder and OCD (anxiety in 30% of ADHD)
- mood disorders
- substance use
- tic disorders
- developmental coordination disorder
- ASD
- learning disorder (MOST common comorbidity)
- eating disorder
Nonpharm treatment for ADHD WITH evidence
- psychoeducation
- parent behaviour training
- classroom management
- daily report card
- FFA supplementation
- exercise
Others: organizational skills, behaviour peer interventions)
AEs of stimulant meds
- low appetite
- sleep difficulties
- moodiness
- irritabilities
- tics
- peripheral vasculopathic sx
- rarely: psychosis, priapism
- slight increase in HR and BP (measure BP at appropriate intervals)
Stimulant medications and growth
- decrease in growth of 2.5cm
- final height minimally affected
- may have delay in pubertal growth spurt
ASD and ADHD overlap
> 50 % of those with ASD meet criteria for ADHD
Medication for ADHD sx in ASD and ID
1st line:
- psychostimulants
but more likely to have side effects and less likley to respond
Preterm behavioural phenotype
- inattention
- internalizing disorders
- social difficulties
(#1 disability = cognitive impariment for ELBW)
