Adolescent Group Flashcards
Updated 05/04/2024
Along with a DSM-5 Diagnosis, what other characteristics of the diagnosis should be included in reports ?
Factors Impacting Mental Health Management
- Severity of disability (functioning)
- Patient’s Ages (Developmental and Chronologic)
- Family’s Means to engage in therapies ($$$, work schedule, communication disorders, languages)
- Relevant Family Co-morbidities
- Relevant Patient Co-morbidities
ADOLESCENT PATIENT
=
DO A HEADSS
SERIOUSLY !
NEVER FORGET HEADSS
What psychosocial and medical issues are Adolescent Mothers more at risk of developing/having?
- Psychological, Physical and Sexual abuse
- Repeated pregnancies
- Low self-esteem
- Anxiety, mood, substance abuse and personality disorders
What are the fetus/newborn(s) of adolescent mothers at risk for, versus the general population?
- Prenatal Death
- Prematurity
- Low Birth Weight and IUGR
- Substance use associated disorders (e.g. FAS, nicotine withdrawal, SSRI withdrawal)
What are the children of adolescent mothers at risk for, versus the general population?
- Growth Delays
- Mood, Anxiety, Personality disorders
- Developmental delays
- Learning disorders
TRUE or FALSE
Regarding adolescent pregnancy, Paternal Involvement is associated with improved outcomes for both the Mother and Child (including those with a history of abuse)
TRUE
Studies have shown that the father being involved with the child’s life in any way is associated with improved psychiatric and health outcomes for both the Mother and Child.
Describe the Medical Home Model
The medical home is a “one-stop-shop” for the patient’s needs
- Accessible and developmentally appropriate
- Comprehensive and coordinated
- Family centered and culturally sensitive
- Compassionate
- Continuous
*Think Cancer Clinic at the KGH
What are the pediatrician’s general goals of care for an adolescent pregnancy?
- Refer to Pediatric Obstetrics Service (technically are ‘high risk’)
- Routine Antenatal care
- Routine Postpartum care
- Access to contraception (Approach this antenatally)
- Specific psychosocial screening (i.e. do a HEADSS)
What birth controls options involve
systemic hormone exposures?
- Oral Contraception
- Nuvaring
- Transdermal Patch
- IM Injection (Depo-provera)
- SubQ infusion device (not in Canada)
[Essentially everything EXCEPT for the IUD, diaphragm and Condoms]
What are the absolute contraindications for systemic hormonal birth control?
- Migraine with aura (progestin-only are ok)
- Clotting disorders or previous un-provoked clots NYD
- Coronary artery disease/cerebro-vascular disease
- Pregnancy
- Personal/Family history of hormone dependant cancers \
(i.e. gynecological, breast and liver)
TRUE or FALSE
Contraception induced amenorrhea is pathologic, and can cause long term issues?
i.e. you SHOULD have a period to be healthy
FALSE
Menses are not required for healthy functioning, and their scheduled released with contraceptive methods is a habitual notion, not a required physiologic one.
TRUE or FALSE
Systemic contraceptive methods cause weight gain
FALSE
- The weight gain observed by birth control is secondary to progesterone induced mild hyperphagia.
- Education on this phenomenon can encourage compliance and prevent unhealthy weight gain.
Give your step wise approach to initiating birth control
The CPS’ systematic Birth Control Initiation
- Ask about current knowledge and educate +/- of each birth control modality
- Detailed History for hematologic, neurologic, vascular, cancer disorders and complete a full HEADSS.
- Physical examination; birth control Initiation is NOT an indication for a pelvic exam. Blood pressure is a must.
- Encourage STI screening
- Pregnancy screen
- Condoms for 14 days after initiation is mandatory to prevent unwanted pregnancy, encourage routine condom use for STIs and optimised birth control.
- Prescribe annually to encourage compliance - this has been statistically shown to prevent unwanted pregnancy.
EPI BULLET
just one
30 % of adolescent females that do not want to get pregnant, also do not use contraception
What are the failure rates for the following modalities
- IUD
- OCP
- Nuvoring
- Transdermal Hormone Patch
- Depoprovera
- Condom/Diaphragm
in pregnancy prevention?
- IUD 0.2 - 0.8 % (local hormone)
- Depoprovera 6 % (systemic hormone)
- OCP 9 % (systemic hormone)
- Nuvoring 9 % (systemic hormone)
- Transdermal Hormone Patch 9 % (systemic hormone)
- Condom 18 % (barrier)
- Diaphragm 12 % (barrier)
Best results are any local/systemic hormone WITH condoms (synergistic impact on failure rates)
What evidence based positive effects are associated with recreational Cannabis use?
None
“While claims regarding the potential effectiveness of medical cannabis in children are widespread, few placebo-controlled clinical trials beyond those focused on DRE have included children[14] or yielded results to support such claims.”
https://cps.ca/en/documents/position/medical-cannabis-for-children-evidence-and-recommendations
What 4 physiologic changes have been observed on brain MRI/fMRI in the context of chronic cannabis use?
(when compared to controls)
- Decreased brain volumes
- Changes in folding patterns
- Decreased white matter
- Decreasing functional efficiency
What is the proposed molecular mechanism for THC-associated developmental changes?
- Growing neurons are exposed to excessive stimulation of the THC-receptors, prompting abnormal concentrations of dopamine/serotonin/norepinephrine.
- This results in an abnormal environment for neurons to grow appropriately, so the neurons are dysmorphic/not-optimized in the end.
- Since brain growth speed is inversely proportional to age, there is more damage at younger ages of exposure.
What medical conditions have demonstrated positive reduction in disease burden, with cannabinoid use ?
Positive Medical Response to Cannabinoids
- Drug-Resistant Epilepsy (36-49 % reduction in sz frequency)
- Autism (Improvements with daily functioning, through sedation)
- Cerebral Palsy (Improved spasticity; adults-only)
- Fragile X (Single study; improved socialisaton and reduced aggression)
- Nausea/Vomitting (third-line anti-emetic in cancer patients)
List 5 medical concerns with acute cannabis intoxication?
- Obtundation (airway concerns)
- Panic Attacks
- Drug induced psychosis
- Drug induced exacerbation of psychotic disorder
- Risk for trauma (i.e. driving/cycling impairment, susceptibility for abuse)
Since legalization, acute intoxications with toddlers has increased 34 %
EPI BULLETS
- 5.6 % of 12th graders report daily cannabis use
- 14 % of HS students report cannabis use in the last 30 days
- Chronic cannabinoid use is associated with a 40 % increase in lifetime risk for a psychotic event
What are the longitudinal concerns associated with chronic cannabinoid use in adolescence?
- Dependance and withdrawal
- Risky seeking behaviours
- Decreased IQ and processing speeds
- Psychotic episode risk
TRUE or FALSE
Patients with chronic disease have a DECREASED risk for engaging in voluntary sexual activities
FALSE
Adolescents with chronic diseases (i.e. DM, CP, epilepsy etc.) actually have higher (> 50 % incidence) rates of engaging in sexual acts when compared with their controls.
They also have higher rates of:
- Sexually transmitted infections
- Sexual abuse (2x the general risk)
List the CPS’ 3 goals of care for adolescents with chronic disease?
- Avoid exacerbations
- Educate to mitigate magnitude of exacerbations
- Empower self-care to decrease the baseline daily effects of their disease
*** An additional goal from another CPS statement include anticipatory guidance regarding sexual abuse. They don’t talk to eachother a lot I’ve discovered.
EPI BULLETS
- 15 % of youth in Canada have a chronic disease
- 89 % have mild disability, <3 % have severe disability
What is your approach to establishing a transition to the adult medical world for your patients with chronic disease?
The CPS’ Transition to the Adult System
- Involve adolescent in their own care as young as possible
- Educate Adolescent and Family on the patient’s condition; appraise their knowledge routinely
- Develop realistic social/educational/work potentials and encourage they meet their best potential
- Empower the adolescent (self-esteem/confidence are key)
- Ensure they are meeting their own adolescent developmental tasks of socialisation, school performance, autonomy
What are some preoccupations adolescents with chronic diseases can have?
- Guilt for cost on family
- Body image
- Relative absence of autonomy to peers
- Feelings of separation from others at school/sport/activities
- Mortality and death
- Ignored as a sexual person (feel incapable/unworthy)
- Baseline anxiety, mood and self-esteem issues
Despite this, adolescents with chronic diseases have shown to be more mature at an earlier age, and have clearer perspectives on stressors versus their peers. Embracing these notions can help alleviate their negative preoccupations.
What deems a Diet as “unhealthy”?
One of the following contexts are in place
- Chronic dieting (> 10 diets/years)
- Fad dieting (e.g. non-Rx ketogenic, paleo, grapefruit)
- Fasting practices (despite recent evidence in adults)
- Meal skipping
- Cigarette use for dieting
- DSM-5 criteria for an Eating Disorder
What types of diets can be encouraged by a pediatrician ?
(2 answers)
- Therapeutic diets as per underlying disease
- When the diet is a shift from poor eating habits to normal healthy ones (e.g. those who call cutting junk a diet)
- Cultural diets with appropriate supplementation
(i.e. veganism, vegetarianism, dairy exclusion)
Are all dieting practices in adolescents consistent with an eating disorder ?
NO
Although adolescents that diet (particularly pre-teens) have a 5-18x increased risk for progressing to an eating disorder.
To diagnose an Eating Disorder refer to the DSM-5 criteria.
What is the best evidence based therapy for patients with Eating Disorders?
Define it
Family Based Therapy
Defined as the child being empowered through the parents to overcome the behaviours associated with their eating disorder at home/school/with friends, as an outpatient.
Describe 2 ways to determine a Treatment Goal Weight
(re: eating disorders)
- Weight for the same percentile as the patient’s height
- i.e. TGWt %ile = Ht %ile for Age*
- Weight as determined by the Age’s 50th %ile for BMI
- i.e. TGWt = 50th %ile BMI for Age*
- Weight at which the patient had their last period (not ideal)
i. e. TGWt = Weight during last period + 2 kg - Previous Weight prior to the development of illness
- There is no correct answer for the BEST option, as per the CPS. Just know 2 of these to apply in case some information above isn’t available.*
What is the goal weight gain for a refeeding eating disorder patient?
0.2 - 0.5 kg/week
(~0.5 - 1 lbs/week)
How should parents and healthcare workers respond to negative eating disorder behaviours during treatment/onward?
- ZERO Tolerance to any behaviours; they are to be stopped with consequences. No warnings allowed.
- Reasonable modifications to the magnitude of consequences should be applied
(e.g. if a girl is bullied at school, and then goes home to purge, the consequences can be less than those of primarily engaging in the activity)
- Consistent improvement is to be rewarded
- Remind Parents and the Patient that persistence of symptoms throughout treatment is expected, NOT a sign of their failure.
List a resource that parents can access for help with their child’s eating disorder?
When asked during an OSCE for a resource, they will fact check you later. There’s no best answer, but you need to have your own strategy in your back pocket.
CPS endorses a book called “Help your teenager beat their eating disorder” and a website called “Maudsley Parents”.
