Adolescent Group Flashcards
Updated 05/04/2024
1
Q
Along with a DSM-5 Diagnosis, what other characteristics of the diagnosis should be included in reports ?
A
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
2
Q
ADOLESCENT PATIENT
=
DO A HEADSS
A
SERIOUSLY !
NEVER FORGET HEADSS
3
Q
What psychosocial and medical issues are Adolescent Mothers more at risk of developing/having?
A
- Psychological, Physical and Sexual abuse
- Repeated pregnancies
- Low self-esteem
- Anxiety, mood, substance abuse and personality disorders
4
Q
What are the fetus/newborn(s) of adolescent mothers at risk for, versus the general population?
A
- Prenatal Death
- Prematurity
- Low Birth Weight and IUGR
- Substance use associated disorders (e.g. FAS, nicotine withdrawal, SSRI withdrawal)
5
Q
What are the children of adolescent mothers at risk for, versus the general population?
A
- Growth Delays
- Mood, Anxiety, Personality disorders
- Developmental delays
- Learning disorders
6
Q
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)
A
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.
7
Q
Describe the Medical Home Model
A
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
8
Q
What are the pediatrician’s general goals of care for an adolescent pregnancy?
A
- 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)
9
Q
What birth controls options involve
systemic hormone exposures?
A
- Oral Contraception
- Nuvaring
- Transdermal Patch
- IM Injection (Depo-provera)
- SubQ infusion device (not in Canada)
[Essentially everything EXCEPT for the IUD, diaphragm and Condoms]
10
Q
What are the absolute contraindications for systemic hormonal birth control?
A
- 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)
11
Q
TRUE or FALSE
Contraception induced amenorrhea is pathologic, and can cause long term issues?
i.e. you SHOULD have a period to be healthy
A
FALSE
Menses are not required for healthy functioning, and their scheduled released with contraceptive methods is a habitual notion, not a required physiologic one.
12
Q
TRUE or FALSE
Systemic contraceptive methods cause weight gain
A
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.
13
Q
Give your step wise approach to initiating birth control
A
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.
14
Q
EPI BULLET
just one
A
30 % of adolescent females that do not want to get pregnant, also do not use contraception
15
Q
What are the failure rates for the following modalities
- IUD
- OCP
- Nuvoring
- Transdermal Hormone Patch
- Depoprovera
- Condom/Diaphragm
in pregnancy prevention?
A
- 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)
16
Q
What evidence based positive effects are associated with recreational Cannabis use?
A
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
17
Q
What 4 physiologic changes have been observed on brain MRI/fMRI in the context of chronic cannabis use?
(when compared to controls)
A
- Decreased brain volumes
- Changes in folding patterns
- Decreased white matter
- Decreasing functional efficiency
18
Q
What is the proposed molecular mechanism for THC-associated developmental changes?
A
- 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.
19
Q
What medical conditions have demonstrated positive reduction in disease burden, with cannabinoid use ?
A
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)
20
Q
List 5 medical concerns with acute cannabis intoxication?
A
- 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 %
21
Q
EPI BULLETS
A
- 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
22
Q
What are the longitudinal concerns associated with chronic cannabinoid use in adolescence?
A
- Dependance and withdrawal
- Risky seeking behaviours
- Decreased IQ and processing speeds
- Psychotic episode risk
23
Q
TRUE or FALSE
Patients with chronic disease have a DECREASED risk for engaging in voluntary sexual activities
A
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)
24
Q
List the CPS’ 3 goals of care for adolescents with chronic disease?
A
- 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.
25
**EPI BULLETS**
* **15 % of youth** in Canada **have** a **chronic disease**
* **89 %** have **mild** disability, **\<3 %** have **severe** disability
26
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_
1. **Involve adolescent** in their own care as young as possible
2. **Educate** Adolescent and Family on the patient's condition; **appraise** their knowledge **routinely**
3. Develop **realistic** social/educational/work **potentials** and encourage they meet their best potential
4. **Empower** the adolescent *(self-esteem/confidence are key)*
5. Ensure they are **meeting their** own adolescent **developmental tasks** of socialisation, school performance, autonomy
27
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
## Footnote
*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*.
28
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**
29
What types of diets can be encouraged by a pediatrician ?
## Footnote
*(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)*
30
Are all dieting practices in adolescents consistent with an eating disorder ?
**NO**
## Footnote
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*.
31
What is the best evidence based therapy for patients with Eating Disorders?
## Footnote
*Define it*
**Family Based Therapy**
## Footnote
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**.
32
Describe 2 ways to determine a Treatment Goal Weight
## Footnote
*(re: eating disorders)*
* Weight for the same percentile as the **patient's height**
## Footnote
* 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.*
33
What is the **goal weight gain** for a refeeding eating disorder patient?
**0.2 - 0.5 kg/week**
*(~0.5 - 1 lbs/week)*
34
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
## Footnote
*(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**.
35
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"*.
36
You have a new diagnosis of an Eating Disorder what's your management approach?
## Footnote
*(I'll put the step-wise suggestions as per CPS)*
Have the **_patient present_** for all these discussions
1. **Assess** for **hospitalization** (*Note concerning physiologic changes )*
2. Identify eating disorders as a **psychiatric issue** and **NOT the fault** of any one **event**, **person** or **upbringing**.
3. Refer to **Nutritionist/Dietician** and/or specialized center
4. Encourage all **caregivers** to be "**on the same page**"
5. **Advise** refeeding **will be difficult** to all parties
6. Provide access to **supportive materials** for reading for each party
7. Establish a **list of behaviours**, highlight the negative physiologic importance of them
8. Establish a **plan**, *sometimes referred to as a contract*, for **privileges** to be allowed based on activity.
9. **Follow-up** as per physiologic/psychologic baseline *(suggest weekly/biweekly)*
37
What the criteria for **admission** to hospital for Eating Disorder Management?
Any of the following
* HR **\< 40 bpm** or other **arrhythmia** present
* BP **\< 80/60 mmHg** or sympt. of **Orthostatic Hypotension**
* **Weight \< 70th % ile** for height or **BMI \< 15**
* Signs of severe **malnutrition** *(think vitamins, anasarca etc)*
* Outpatient **refeeding syndrome**
* **Failure** of **Outpatient** Therapy
38
How does one **weigh** a patient with **an eating disorder** in the outpatient setting ?
The CPS suggests
1. **Interview** the patient **alone/chaperoned**
2. Provide gown, **ask to dress down** to only underwear **then leave the room**.
3. Have patient **void**, **with** their appropriate **parent attending**, to assure a full bladder is emptied.
4. Have **numbers recorded without** **patient seeing** them, giving non-specific good/bad feedback as to the result.
39
Define the **Treatment Goal Weight** in treatment of Anorexia Nervosa
**Treatment Goal Weight**
The **weight** required for the body to obtain **normal physiologic** **functioning** on a biochemical and clinical level.
The TGW can be determined through
* **Previous growth** curves *(growth potential)*
* **Mathematically** with several different equations
* **Bone** Aging *(if above aren't readily available/applicable)*
*If you do NOT have the aforementioned information, TGW is not determined, but you follow the physiology on a clinical level to determine when normalcy is met.*
40
How often must a Treatment Goal Weight be **reassessed** for the management of Anorexia nervosa?
Every **3 to 6 months**
**OR**
A significant **change in** **physiology** or general health occurs.
41
**EPI BULLETS**
* **17 %** **of houses** in Canada **have** a **firearm**
* Odds ratio of completing suicide is **3.24** if a firearm is accesible
* **Gang Involvement** is associated with a **+20 %** chance of being **faced with gun** violence; _+11 %_ if _previously_ involved with gangs; **+ \< 1 %** if **no gang** involvement
* Firearm access and home violence **synergistically** increase the risk for homicide
* California study showed that risk for **gun-related events** **increased** with children with **military parents**
42
What developmental risk factors for **Children** and **Adolescents** place them at risk for **firearm** associated injury?
**CHILDREN**:
* Poor **cognitive** understanding of cause/effect associated with the danger of a firearm.
* Poor **coordination** of holding the weapon means simply handling the gun is dangerous.
**ADOLESCENT**:
* **Poor** self-**regulation** and **forethought** increases the odds they will engage in dangerous activities with the firearm *(e.g. shooting stuff in backyard, making youtube videos with armed guns)*
43
What advice should a pediatrician give regarding the use of **faux guns**?
## Footnote
*Faux guns include air guns, paintball guns or potato cannons*
The recreational use **at home** should be completely **discouraged**. These activities should be done **always under supervision** in an appropriate **recreational facility**.
*Injuries suffered from a faux-gun should be treated in the same ATLS format as a gunshot wound.*
44
What "social" **habits**/behaviours should be screened for during adolescent evaluations as per the Greig Health Record ?
## Footnote
*CPS endorses the GHR so we gotta know it*
* **Gambling**
* **Gaming** habits
* **Sexting**/Online sexual presence
* Phone/**Screen** time
* **Supplements** *(work-out, diet pills etc.)*
* **Smoking** *(e-cigarettes, cigarettes, hookah etc.)*
* Marijuana and Prescription/Illicit **drugs**
* **Alcohol**
## Footnote
*All of the above are assessed in the CPS Statements with CBT approaches like the 5 A's; Ask, Advise, Agree, Assist, re-Assess.*
45
What are the definitions of **TRUE** vs. **RELATIVELY** homeless youths?
**True** *or (absolute)* **homeless** are the classic image of a homeless person. Seeking homeless shelters, living in makeshift shelters or abandoned buildings.
**Relatively** **homeless** are more common, and called the hidden/secret/invisible homeless. They obtain shelter in homes through couch-surfing, risky behaviours *(e.g. survival sex, crime engagement, illegal labour).*
46
EPI BULLETS
* Canadian **Prevalence** of **homelessness** *(True/Relative)* is **~150,000**
* **Abused Females** are **4x more** likely the become **street involved**
47
What psychosocial risks are associated with **Street Involved Youth** specifically?
* **Survival** Sex
* **Illegal** activities *(survival crime)*
* Poor **access** to Healthcare/Social assistance
* Psychological/Psychiatric **disorder**s/traits
48
What **medical** risks are associated with **Street Involved Youth** specifically, and must be screened for?
* Poor **asthma control**
* **Nutrition**al deficiencies *(think vitamins, essential metabolites)*
* **Tuberculosis** consideration
* **S*****taph**ylococcus* *aureus* infections *(always cover for it)*
* Foot and **Skin care**
* **Dental** Health
* **S**exually **T**ransmitted **D**iseases and access to **birth control**
* **Substance** abuse
* **Trauma** from gang activities/abuse
49
What **barriers** does the CPS Identify as important to address for **Street Involved Youth**?
* Anger/**Distrust** for Adults, Authority and ***"The System"***
* Knowledge on Where/How to **access** help
* Adult **consent** required for some therapies *(province dependant)*
* Health **insurance access**
* **Drug coverage**
* Drug **dosing/admin**istration **feasibility**
50
EPI BULLETS
* **1 / 5 teens** have **sexted** or posted sexual media
* **50 %** have **received** a sext
* **40 %** have **sent** a sext
51
What is the CPS' practice stance on sexting ?
**Sexting is a risky behaviour**
The management for all risky behaviours by the CPS is the 5 A's
* **Ask** *about sexting*
* **Advise** *about the negative consequences*
* **Agree** *on a plan to stop sexting*
* **Arrange** *for patients to cope/respond to requests to sext*
* **Assist** *with any problems faced after implementation*
* **Advocate** *for schools to educate on sexting risks*
52
TRUE or FALSE
## Footnote
STI screening is required for all teens
**Sort of both**
1. **G**onorrhea **and C**hlamydia screening **for ALL** sexually active **females**, and those **males** with **risk factors** *(unprotected sex)*
2. **HIV** Screening for **ALL sexually active** adolescents **\> 15 y.o.**
3. **HIV** screening for sexually active youth ( **\< 15 y.o.**) if they have **risk factors**
53
List 4 risk factors for **Melanoma**
* Fair skin *(baseline pallor, red hair, freckling)*
* Several nevi *(moles)*
* Family History of skin cancers
* Frequent sun exposure
54
What benefits do tanning beds provide?
**None**
* There's NO worthwhile Vitamin D production, which should be supplemented daily for all Canadians*
* (400 IU routine, 600 IU for the Northern, Dark skinned, chronic diseased patients)*
55
True or False
## Footnote
Skin cancer risk is proportional to tanning bed exposure-time
**True**
* Think of tanning bed time like pack-years*
* The intensity, duration and the frequency of exposures are **all** proportional to cancer risk.*
56
Which of the following activities can develop patterns of addiction *(dependance, withdrawal, fMRI changes)*
* Cigarettes
* Marijuana/THC Products
* E-cigarettes/Vaping
* Tanning Beds
**_All of the above_**
## Footnote
* These exposures have been found to actually **increase endorphin** release in the brain through various mechanisms of improved self-esteem. B-endorphins have been specifically seen to rise with tanning bed exposures - yes really!.*
* We must address appropriately with screening for dependency and withdrawal when removed as a stimulus.*
57
True or False
## Footnote
Tanning Bed intensity and proper function is annually regulated
**_False_**
## Footnote
Tanning beds are regulated at the **manufacturer level,** and tanning facilities are inspected once (when opened or when renovated). The beds themselves **can have ANY functional capacity**, so you don't know what exposures you're getting after their inspection.
*There's no legislation to protect the consumer*
58
List the 3 essential recommendations from the CPS regarding Tanning beds
* **Ask** about tanning bed use from age 14 and above, or if suspected based on history/physical exam
* Actively **discourage** use
* **Advocate** for government regulation
59
What are the key differences between cigarettes and the following tobacco/nicotine sources
* Cigars
* Shisha
* Beedi
* Chewing
* E-cigarettes
* Cigars
* **4x more** **nicotine** so higher risk for toxicity
* Oropharyngeal **cancer risks**.
* More **$$$**
* Shisha/Hookah:
* Increased **esophageal cancer** risks
* **Coal accelerant** exposure
* Water **does NOT filter** anything
* **Herpes** labialis
* Beedi *(south-asian mini cigars)*
* **3-5x more nicotine**
* Chewing Tobacco/Snuff:
* Massive **oropharyngeal disease** risk *(infections, cancers, dentition disease, rhinitis)*
* E-cigarettes:
* Very high risk for **nicotine toxicity**.
* E-cigarette associated **RDS**.
* Burning risk.
* **NOT** to be used as **a means of cessatio**n.
60
What **topics** does the CPS suggest **to address** with patients for evidence based prevention of **smoking**?
* Impact on **fetus** if pregnant
* **Cosmetic** outcomes *(e.g. poor scarring, skin color, smell, breath, teeth yellowing/gum disease)*
* Performance in **School/Sport** *(e.g. addiction associated anxiety on attention, poor physical performance)*
* Financial **Cost** and potential for the same funds
* **Personal** short/long-term **health risks**
* **Impact** your smoking has **on others** around you
* **Being manipulated** by Big Tobacco *(seriously that's something they wrote for adolescents)*
61
List the **best** evidence based **interventions** to prevent or stop smoking behaviours
## Footnote
*(as per the CPS)*
* **Face-to-face counselling** with easy, routine follow-up through text/e-mail/phone calls
* Education on smoking's negative impact of on factors **important** to the **patient** *(e.g. cosmetics, money, sports performance)*
* **Advocate** for **Taxation** of smoking products, educational **labels**, access restriction, youth marketing restriction, **smoke-free spaces**.
62
**EPI BULLET**
*Another lonely one*
* **90 % of** adult **smokers** started at **\< 18 years** old
63
What is your medical management plan when assisting a patient **quit smoking**?
## Footnote
*(When they have commited to start quitting)*
**After** establishing **behavioural** therapies/interventions for addiction cessation the following step-wise Rx can be used
1. Nicotine Replacement Therapy (**NRT**) *(patch or gum only, inhaled replacements aren't approved for adolescents)*
2. **Buproprion** *(if no seizures, eating disorders or recent head trauma)*
3. **Varenicline** *(if no somnambulism)*
*Do **NOT** prescribe **Clonidine**, **Nortriptyline**, **Cytisine** as they are not studied in adolescents*
64
What are positive **factors** that can **facilitate** smoking **cessation**?
* Advanced **Age**
* **Pregnancy**
* **Male**
* Scholastic and Sports **Success**
* Psychosocial/Cessation **Support** in **Family**
* **_CYP2AG_** nicotine rapid metabolizer *(How the heck are we supposed to know that)*
65
What are **negative** factors that can **deter** smoking **cessation**?
Adolescent specific:
* **Perceived** lack of **autonomy**
* **Fear** of peer **rejection** *(peer pressure)*
* Normal developmental drive to experiment
General:
* Presence of addiction with **withdrawal symptoms**
* Psychiatric **comorbidities**
* Marijuana, Illicit **Drug** or Alcohol **use**
* Chronic **Illness**
* Peer/**Family** Tobacco **use**
* **Weight** concerns *(Over or underweight)*
66
EPI BULLETS
* Patient **age is proportional** **to** smoking **prevalence**
* **Policy changes** resulted in **2-3x less** adolescent **smoking** since 1999
* **6/10 adolescent** smokers seriously **want to quit** in next 6mo
* **LGBTQ** and **Indigenous** adoles. are **5x more** likely to **smoke**
67
What are 6 risk factors for smoking initiation?
**CPS endorses the following**
* **Parental** smoking
* Low **socioeconomic status**
* **Lack** of parental **support** in smoking cessation
* **Misinformation** regarding smoking health risks
* Easy **access** to cigarettes
* **Previous experience**/experimentation in smoking
* Psychologic/**Psychiatric disorders**
* Poor **school performance**/low **self-esteem**
* **Adverse** Childhood Events
* Substance **abuse**
68
What are the **acute concerns** for **tobacco** use?
* **Nicotine** toxicity
* **Contaminant** effect on body *(e.g. e-cigarette additives)*
* Predisposition to **addiction**
* Lung/Cardiac/Anxiety **disease exacerbation**
69
What does **smoking** do to patients with **Cystic Fibrosis**?
## Footnote
*(for education/advisement stations)*
* **More** admissions for **chest infections** & decompensation
* **Hastened decline** in lung **function**
* **Nutritional deficits** requiring MORE enteral supplementation *(inconvenient day-to-day)*
70
What does **smoking** do to patients with **Juvenile Idiopathic Arthritis**?
## Footnote
*(for education/advisement stations)*
* Worsened **osteopenia**
* **Increased** risk and magnitude of **cardio**_vascular_** disease**
* Identified Premature **Death** risk **increase**
71
What does **smoking** do to patients with **Sickle Cell Anemia**?
## Footnote
*(for education/advisement stations)*
* More Acute **Chest Syndrome**
* More **Strokes**
* Hastened **renal disease** progression
72
What does **smoking** do to the general **cancer patient**?
## Footnote
*(for education/advisement stations)*
The **risks associated with** having a **cancer** and being on **chemotherapy** *(e.g. clots, strokes, poor healing, infections)* are **amplified**.
73
What does **smoking** do to patients with **diabetes mellitus**?
## Footnote
*(for education/advisement stations)*
Diabetes Mellitus is a **microvascular disease**, so it's **synergistic with** the vascular damage caused by **smoking**.
**Morbidity and Mortality** of DM issues\* are increased by **50-75 %**
*\*renal, retinal, cardiovascular, neuropathic vascular diseases*
74
List the CPS**'** **_5 A's_** for effective **risky behaviour _counselling_**
**ASK** about the behaviour
**ADVISE** of the health risks and benefits of decreasing/ceasing
**ASSESS** their motivation to decrease/cease
**ASSIST** them in cessation
**ARRANGE** for follow-up
75
What are the **3 Methods** to treat **_Anxiety_** in the Pediatric *(and adult)* populations as proposed by the CPS ?
Anxiety Management Modalities to Consider
* Psycho**education**
* Psycho**therapy** *(CBT, Family therapy)*
* **Pharmaco**-therapy
76
Describe **“Positive Parenting”**
*as per the CPS*
**Positive Parenting**
## Footnote
The definition is not outright given, its purpose is to encourage **healthy responses** to the child's behaviors and create a **positive** environment at **home**.
**Positive Parenting is** an arbitrary label given to the process of following through with **Psychoeducation**.
77
Give 4 examples of "**Positive Parenting"** provided by the CPS
_Inexhaustive Positive Parenting Methods_
* **Recognize** and **describe emotions** and/or somatizations
* Addressing emotions, and ‘**avoid avoiding**’.
* **Validate anxieties** and counter with small manageable solutions.
* **Encourage** and **facilitate** friendships/**play** *(playdates, clubs, sports)*
* Consistent, specific and **unique praise**, not generic applauds.
* **Encourage** autonomy when possible
* **Liase** with teachers, other parents, activity coordinators
* **Model healthy coping** mechanisms *(preventive, reactive and reflective)*
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EPI BULLETS
* Pre-pandemic incidence of **pediatric anxiety** was **12.9 %** *(doubled over 7 years)*
* Cochrane review showed Primary **Anxiety Remission** in children who engaged in **CBT** versus inaction/waitlisted kids (**OR 5.45** 95% CI, n = 6000)
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When are **SSRIs and SNRIs** indicated for the management of **Anxiety**?
Pharmacotherapy is indicated in children **6 - 18 years old** with Moderate-Severe disability +/- concomitant CBT.
**Psychotherapy should be the primary** **management** with pharmacotherapy as an adjuvant to facilitate psychotherapy.
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# Not CPS Statement Based
What are the side effects and trade names for the following drugs?
* Citalopram
* Escitalopram
* Fluvoxamine
* Sertraline
* Fluoxetine
* Venlaxafine
* Duloxetine
All anti-depressants have a tiny but relevant risk for **Suicidality**, **Mania**, **Bleeding**, **Serotonin Syndrome**,
**S**elective **S**erotonin **R**euptake **I**nhibitors
* Citalopram (Celexa) - prolonged QTc
* Escitalopram (Cipralex)
* Fluvoxamine (Luvox)
* Sertraline (Zoloft)
* Fluoxetine (Prozac)
*GI upset, Hyperactivity, Sexual dysfunction, Weight changes, myalgias, headache*
**S**elective **N**orepineph. **R**euptake **I**nhibitors
* Venlaxafine (Effexor)
* Duloxetine (Cymbalta)
*Weight, Energy and Sleep changes, Sexual dysfunc., Dry Mouth, Hypertension, Tachycardia, Myalgia*
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**Remember to practice using the following testing tools for your exam**
**[Available for free from the CPS]**
[Mental Health: Screening Tools and Rating Scales | Canadian Paediatric Society (cps.ca)](https://cps.ca/mental-health-screening-tools)
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List the **5 themes** for _Policy Makers_, that the CPS requests regarding **Social Media Regulation**
_The CPS suggest Policy Makers_
- Improve **Age-Verification** Standards
- **Publicize and fund research** into social-media's impact on children
- **Regulate data collection**/use from/for minors
- **Mandate** _critical appraisal of social media_ be implemented in formal education
- **Restrict** harmful advertising being directed at minors
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List the 4 points the CPS requests from _Social Media Developers_
_CPS' Request from Social Media Developers_
(1) *Transparency* on data collection and use
(2) *Prioritize* Child and Youth *Health* when developing new programs
(3) Ensure **youth have greater control** over the content they view
(4) Make infrastructure that **protects youth from hate**ful content & bullying.
(5) Make infrastructure that **protects youth from harm**ful interactions and sexual exploitation
*Points 4 and 5 are consolidated by the CPS, but I want to highlight the importance of not just shielding children from hate speech but also the real risk of being groomed online for eventual physical abuse.*
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What is the adolescent diagnostic criteria for **Gender Dysphoria** ?
*(as per the DSM-V)*
_DSM-V Diagnostic Criteria for Adolescent Gender Dysphoria_
**Criteria A - Marked gender (≥6 months) manifested by 2/6:**
- Marked incongruence between one's experienced/expressed gender and their current or anticipated physical characteristics
- A strong *_desire to remove/prevent_* incongruent sexual physical characteristics
- A strong desire **to have** the sexual **characteristics of another gender**
- A strong desire to **be of another gender**
- A strong desire to be **treated as another gender**
- A strong conviction that one has the typical feelings and reactions of the other gender
Criteria B - The condition is associated with clinically significant **distress and functional impairment**
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**TRUE** or **FALSE**
*_Hormone/Puberty Blockade is reversible_*, and default endogenous hormone production will resume upon drug cessation
**TRUE**
Several studies have demonstrated reversibility of puberty blockade, but the *CPS does NOT endorse a specific cut-off age of when this reversibility stops.* The default hormonal pattern will resume by 6 months post-GnRHa cessation.
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At what age does a parent **stop** having the arbitrary right to view their child's medical record **without the child's consent **?
| i.e. at what age do we start respecting a child's privacy
Québec : 14 years old
Newfoundland : 16 years old
Other Provinces : When the child is deemed a mature decision-maker.
*This protects a physician from an adolescent who requests confidentiality **against medical advice**. If the child refuses to acknowledge the gravity of an issue, and the need for their guardians' invovlement, that is recognized as a risk to themselves.*
## Footnote
https://cps.ca/en/documents/position/privacy-and-confidentiality-in-adolescent-health-care
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**When** should you present your personal policy in **respecting adolescent confidentiality** to parents and patient ?
**As soon as possible**
This allows you to prepare the family for the expectation that you will speak with the adolescent privately for a HEADSS, collateral history taking and abuse screening. This means explaining how you will do it, whether you get another person present and where the conversation will take place.
**Remember:** *"Should a physician feel uncomfortable about being alone with a patient or reviewing certain sensitive topics, it is appropriate to consider a chaperoned discussion with another HCP present"*
## Footnote
https://cps.ca/en/documents/position/privacy-and-confidentiality-in-adolescent-health-care
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