Bad news + Behavioural problems Flashcards
What factors to consider when delivering bad news?
Setting - private place, comfortable seating, face patient, have tissues ready, ensure confidentiality, ask if they want someone else present, turn phone to silent, signpost conversation
Perception - check pt perspective, what they already know
Invitation - ask pt what they would like to know
Knowledge - provide info in small chunks
Empathy + compassion
Strategy + summary - arrange FU + treatment plan
Causes of behavioural problems
Sensory: hearing or vision impairment
Medical:
Central causes: head trauma, mass
Metabolic: hypo/hyperthyroidism, electrolyte abnormalities, DKA, anemia
Medication
Psych:
Dementia
Depression
Bipolar
Schizophrenia
GAD/ OCD/ PTSD/ ED
Personality disorders
Substance use
Learning disorders
ASD
Conduct disorder
ADHD
Oppositional defiant disorder
Social:
Abuse or neglect
Family chaos: poverty, food insecurity
Peer issues
Parental expectations
Types of bipolar
1 = manic/ mixed episode, depression not needed
2 = depression + hypomania
Cyclothymic = several hypomanic + depressive
Rapid cycling = 2-3 days between manic + depressed
Sx of mania
GIDDINESS
Grandiosity
Increased goal actibity
Decreased judgement
Distractibility
Irritability
Need for sleep decreased
Euphoria
Speedy thoughts
Speedy talk
Rx for mania, depression, BP1 and BP2 in bipolar
Mania
Lithium, quetiapine, divalproex, aripiprazole, paliperidone
Agitation: aripiprazole 9.75mg IM or lorazepam 2mg IM
Depression:
Quetiapine, lithium, lamotrigine
Maintenance meds
BP1:
Lithium, quetiapine, divalproex, lamotrigine
BP2:
Quetiapine, lithium, lamotrigine
Lithium monitoring - measuring serum lithium + what to measure while on lithium
12 hrs post dose
5 days after dose change
Cr + TSH + calcium every 3-6 months
AP monitoring
BP
FPG + lipids every year
Criteria for ASD and domains
ADI-R criteria
2 domains: social communication impairment + restricted, repetitive patterns in behaviours + interests
RF for ASD
Genetics
Prenatal (older parents, maternal obesity/ DM/ HTN/ infection, close spacing of pregnancies)
Postnatal (low birth weight, prematurity)
Sx of ASD
Parental concerns, developmental regression, loss of social behaviour + communication
6-12 m/o: reduced smiling, limited eye contact, limited sharing of sounds, smiles or expression, decreased babbling or gestures
9-12 mo: repetitive behaviours, unusual play
12-18 mo: no single word, no compensatory gestures like pointing, no pretend play, no joint attention
15-24 mo: diminished or no spontaneous two word phrases
AUTISTICS
Again + again (repetitive behaviour)
Unusual abilities
Talking delay
IQ subnormal
Social development poor
Three years onset
Inherited component
Cognitive impairment
Self injury
Common comorbidities with ASD
Seizures, sleep disturbance, GI problems
Screening tools for ASD
M-CHAT
Social Responsiveness scale
Autism Spectrum Rating Scale
Screening Tool for Autism in Two y/o (STAT)
Rapid Interactive Screening Test for Autism in Toddlers (RITA-T)
Management of ASD
Refer to peds or psych
Behaviour modification with stimulus, response + reward
Pharmologic tx for symptoms
Repetitive behaviour - SSRI, AP, valproic acid
Hyperactivity - stimulant
Aggression - AP, anticonvulsant, SSRI, BB
Sleep dysfunction - melatonin, ramelteon, antihistamine, mirtazapine
Anxiety - SSRI, buproprion, mirtazapine
Depression - SSRI
Bipolar phenotype - lithium, anticonvulsant
Management of ASD
Refer to peds or psych
Behaviour modification with stimulus, response + reward
Pharmologic tx for symptoms
Repetitive behaviour - SSRI, AP, valproic acid
Hyperactivity - stimulant
Aggression - AP, anticonvulsant, SSRI, BB
Sleep dysfunction - melatonin, ramelteon, antihistamine, mirtazapine
Anxiety - SSRI, buproprion, mirtazapine
Depression - SSRI
Bipolar phecnotype - lithium, anticonvulsant
What is conduct disorder?
Longstanding pattern of violations of rules and antisocial behaviour
RF for conduct disorder
Male
Low SES
Familial aggression
Sx of conduct disorder
Behavioural difficulties
No concern for others
Little guilt about damage caused
Aggression to people + animals
Destruction of property
Deceitfulness and theft
Serious violation of rules
Comorbidities with conduct disorder
Axis 1 = ADHD, depression, bipolar, anxiety, PTSD, SU, suicide
Axis 2 = BPD, APD, developmental delay
Axis 3 = head trauma, seizures
DSM dx of conduct disorder
Repetitive + persistent pattern of behaviour in which basic rights of others or rules are violated
3 or more of following criteria:
Aggression to people and animals
Destruction of property
Deceitfulness + theft
Serious violation of rules
Management of conduct disorder
Parent management training
Individual + family therapy
Aggression: Ritalin, buproprion, dilantin, clonidine, lithium
RF for ADHD
Fam hx
Sx of ADHD
poor organisational skills, anger control issues, difficulty maintaining routines, addictions, frequent accidents, difficulty completing assignments, chronic underachievement
Dx of ADHD
meet criteria for inattentive or hyperactive type, sx present by 12, must impair individual in 2 or more roles (work, school, home), last 6 months, SNAP-IV, Weiss or ASRS
Rx for ADHD
Parent management training, social skills training, CBT, mindfulness, diet + exercise
No stimulants <6y/o - use behaviour therapy
Screen for sudden cardiac death, measure BP, HR and cardiac exam
Accommodations for school/ work
Adderall - amphetamine
Biphentin - methylphenidate
Concerta - methylphenidate
Vyvanse - lisdexamfetamine
Psychostimulants + non-psychostimulants
Psychostimulants
methylphenidate, dextroamphetamine, amphetamine mixed salts, lisdexamfetamine
Non-Psychostimulants
selective norepinephrine reuptake inhibitors (atomoxetine)
selective alpha2 adrenergic receptor agonist (guanfacine
Adjunct to meds for behavioural issues
Time management teaching
Social skills training
Environmental changes
CBT
What to monitor in ADHD treatment
height + weight
Classes of ADHD meds
stimulants, SNRI (atomoxetine), alpha adrenergic receptor agonist (Intuniv)
Safety risks in ADHD
driving MVAs
ASD criteria
persistent deficits in social communication + interaction, multiple contexts, not etter explained by IDDs
Hyperactive sx of ADHD
fidgets, leaves seat, constantly on the go, talks excessively, blurts out answers, trouble waiting turn, interrupts others
Attention deficit sx of ADHD
makes careless mistakes, difficulty holding attention on tasks, doesn’t seem to listen when spoken to, trouble organising tasks, avoids tasks requiring sustained mental effort, loses things, easily distracted, forgetful
ASD screening tool
M CHAT R/F
How to treat behavioural issues
refer to psych, counselling, family therapy, melatonin
ASD ddx
global dev delay, social comm disorder, epilepsy, anxiety, hearing impairment, OCD , add, conduct disorder
Conduct disorder sx
repetitive, persistent, violation of social norms, running away, rule breaking, violent,
Oppositional defiant disorder sx
irritable, defiant, vindictive, rx w/ cbt, psychotherapy, fam therapy, social skills training
Bedwetting rx
bedwetting alarms, desmopressin short term, star chart, involve in cleanup
stuttering - who is at higher risk, rx
males 4x more, no meds, SLP
