Bad news + Behavioural problems

Question 1

What factors to consider when delivering bad news?

Answer 1

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

Question 2

Causes of behavioural problems

Answer 2

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

Question 3

Types of bipolar

Answer 3

1 = manic/ mixed episode, depression not needed
2 = depression + hypomania
Cyclothymic = several hypomanic + depressive
Rapid cycling = 2-3 days between manic + depressed

Question 4

Sx of mania

Answer 4

GIDDINESS
Grandiosity
Increased goal actibity
Decreased judgement
Distractibility
Irritability
Need for sleep decreased
Euphoria
Speedy thoughts
Speedy talk

Question 5

Rx for mania, depression, BP1 and BP2 in bipolar

Answer 5

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

Question 6

Lithium monitoring - measuring serum lithium + what to measure while on lithium

Answer 6

12 hrs post dose
5 days after dose change
Cr + TSH + calcium every 3-6 months

Question 7

AP monitoring

Answer 7

BP
FPG + lipids every year

Question 8

Criteria for ASD and domains

Answer 8

ADI-R criteria
2 domains: social communication impairment + restricted, repetitive patterns in behaviours + interests

Question 9

RF for ASD

Answer 9

Genetics
Prenatal (older parents, maternal obesity/ DM/ HTN/ infection, close spacing of pregnancies)
Postnatal (low birth weight, prematurity)

Question 10

Sx of ASD

Answer 10

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

Question 11

Common comorbidities with ASD

Answer 11

Seizures, sleep disturbance, GI problems

Question 12

Screening tools for ASD

Answer 12

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)

Question 13

Management of ASD

Answer 13

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

Question 14

Management of ASD

Answer 14

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

Question 15

What is conduct disorder?

Answer 15

Longstanding pattern of violations of rules and antisocial behaviour

Question 16

RF for conduct disorder

Answer 16

Male
Low SES
Familial aggression

Question 17

Sx of conduct disorder

Answer 17

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

Question 18

Comorbidities with conduct disorder

Answer 18

Axis 1 = ADHD, depression, bipolar, anxiety, PTSD, SU, suicide
Axis 2 = BPD, APD, developmental delay
Axis 3 = head trauma, seizures

Question 19

DSM dx of conduct disorder

Answer 19

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

Question 20

Management of conduct disorder

Answer 20

Parent management training
Individual + family therapy
Aggression: Ritalin, buproprion, dilantin, clonidine, lithium

Question 21

RF for ADHD

Answer 21

Fam hx

Question 22

Sx of ADHD

Answer 22

poor organisational skills, anger control issues, difficulty maintaining routines, addictions, frequent accidents, difficulty completing assignments, chronic underachievement

Question 23

Dx of ADHD

Answer 23

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

Question 24

Rx for ADHD

Answer 24

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

Question 25

Psychostimulants + non-psychostimulants

Answer 25

Psychostimulants
methylphenidate, dextroamphetamine, amphetamine mixed salts, lisdexamfetamine
Non-Psychostimulants
selective norepinephrine reuptake inhibitors (atomoxetine)
selective alpha2 adrenergic receptor agonist (guanfacine

Question 26

Adjunct to meds for behavioural issues

Answer 26

Time management teaching
Social skills training
Environmental changes
CBT

Question 27

What to monitor in ADHD treatment

Answer 27

height + weight

Question 28

Classes of ADHD meds

Answer 28

stimulants, SNRI (atomoxetine), alpha adrenergic receptor agonist (Intuniv)

Question 29

Safety risks in ADHD

Answer 29

driving MVAs

Question 30

ASD criteria

Answer 30

persistent deficits in social communication + interaction, multiple contexts, not etter explained by IDDs

Question 31

Hyperactive sx of ADHD

Answer 31

fidgets, leaves seat, constantly on the go, talks excessively, blurts out answers, trouble waiting turn, interrupts others

Question 32

Attention deficit sx of ADHD

Answer 32

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

Question 33

ASD screening tool

Answer 33

M CHAT R/F

Question 34

How to treat behavioural issues

Answer 34

refer to psych, counselling, family therapy, melatonin

Question 35

ASD ddx

Answer 35

global dev delay, social comm disorder, epilepsy, anxiety, hearing impairment, OCD , add, conduct disorder

Question 36

Conduct disorder sx

Answer 36

repetitive, persistent, violation of social norms, running away, rule breaking, violent,

Question 37

Oppositional defiant disorder sx

Answer 37

irritable, defiant, vindictive, rx w/ cbt, psychotherapy, fam therapy, social skills training

Question 38

Bedwetting rx

Answer 38

bedwetting alarms, desmopressin short term, star chart, involve in cleanup

Question 39

stuttering - who is at higher risk, rx

Answer 39

males 4x more, no meds, SLP