Behavioral Health -- Sleep and Neuropsych

Question 1

Sleep for infants 4-12 months old

Answer 1

12-16 hours per 24 hours including naps

Question 2

Sleep for children 1-2 years old

Answer 2

11-14 hours per 24 hours including naps

Question 3

Sleep for children 3-5 years old

Answer 3

10-13 hours per 24 hours including naps

Question 4

Sleep for children 6-12 years old

Answer 4

9-12 hours per 24 hours

Question 5

Sleep for children 13-18 years old

Answer 5

8 to 10 hours per 24 hours

Question 6

BEARS screening for sleep problems

Answer 6

B is for Bedtime Problems
E is for Excessive Daytime Sleepiness
A is for Awakenings During the Night
R is for Regularity and Duration of Sleep
S is for Snoring

Question 7

What is behavioral insomnia of childhood (with 3 subtypes)?

Answer 7

It is a cluster of insomnia disorders related to falling asleep and waking up. All 3 types include the primary difficulties of falling asleep independently and frequent night waking.

3 subtypes

• Sleep onset
• Limit setting
• Combined

Question 8

Who does behavioral insomnia of childhood affect?

Answer 8

20-30% of children under age 3

Question 9

Sleep onset type behavioral insomnia of childhood (3)

Answer 9

1. Associated with negative sleep associations.
2. Child that needs rocked to sleep, to watch television or the presence of a parent to fall asleep.
3. Rely on the presence of something to help them sleep.

Question 10

Limit onset type behavioral insomnia of childhood (2)

Answer 10

1. Child who refuses to go to bed or make repeated request to delay bedtime.
2. Limit setting is more attention seeking behavior to prolong going to sleep.

Question 11

Diagnosis of (4) and treatment (5) of behavioral insomnia of childhood

Answer 11

Diagnosis

1. Done through a thorough and detailed history
2. Nature and duration of the complaint
3. Previous attempts to fix the problem
4. Keeping a sleep journal of when and for how long the child sleeps

Treatment
1. First line: sleep hygiene
~Followed by 1 or more of the following~
2. Extinction
3. Positive routines
4. Bedtime fading
5. Schedules awakening

Question 12

Melatonin (4)

Answer 12

1. Acts on the circadian rhythm to regulates sleep
2. Research points out that there is improvement in sleep duration as well as improvement in sleep onset but no change in night waking
   a. Improvements in sleep duration and sleep onset latency, nighttime awakenings were unchanged
3. May be helpful in Autism Spectrum as there have decreased night melatonin level.
4. Relatively benign side effect profile

Question 13

What are parasomnias?

Answer 13

They are a category of sleep disorders that involve abnormal/unnatural movements, behaviors, emotions, perceptions and dreams that occur while falling asleep or sleeping.

Question 14

What are the most common parasomnias in childhood? (3)

Answer 14

1. Confusional arousals
2. Sleep Terrors
3. Sleep walking

Question 15

Confusional Arousals (5)

Answer 15

Presentation:

1. Sits up
2. Very distressed
3. Cry out for help and is hard to console them
4. Not usually flushed or sweating.
5. Must eliminate seizures if there are abnormal movements

Question 16

Clinical Presentation of night terrors or sleep terror (8)

Answer 16

1. Mimic partial complex seizures
2. Occur in 6% of children
3. Peak incidence in preschool and early school aged child
4. Episode generally occurs within two hours of falling asleep
5. Child’s eye open, sits up, glazed look and does not respond to parent
6. Lasts about ten minutes and child falls back to sleep
7. No recollection of the episode
8. Rapid partial arousal from a slow deep sleep

Question 17

Sleep terrors (3) vs Sleep walking (1)

Answer 17

Terrors:

1. Waking up abruptly
2. Screaming,
3. Agitated accompanied by flushing, diaphoresis and tachycardia

Walking:
Mild to severe from walking or crawling peacefully to running or jumping out of windows etc.

Question 18

Parasomnias Diagnostics (3)

Answer 18

1. EEG normal
2. History
   i. Rare but can continue into adolescents
   ii. Sleep deprivation makes them worse
3. If persists despite adequate sleep schedule, a sleep study to rule out obstructive sleep apnea

Question 19

Parasomnias Treatment: Mild (3) vs Severe (3)

Answer 19

Mild cases

i. 1-2 times per month
ii. No treatment necessary
iii. Parent education

More severe cases

i. Become associated with daytime mood or behavioral disturbances, when the safety of the child is a concern, a sleep study should be considered.
ii. If the symptoms occur at the same time every night, scheduled awakenings are a behavior technique that can be used.
iii. Use behavioral management over drugs when at all possible

Question 20

Benign Neonatal Sleep Myoclonus (6)

Answer 20

1. Sudden brief jerks as the child falls asleep
2. Begin in neonatal period and occur as the child is in quiet phase of sleep
3. The jerking movement start in one extremity and move to another extremity—upper tend to be involved more than lower extremity
4. Jerks occur every few seconds for several seconds
5. Can last up to 12 hours
6. Not epilepsy

Question 21

Assessment of Mental Health Disorders (6)

Answer 21

1. Understand Functional Impairment
2. Comprehensive health history
3. Development of a multigenerational family history using genograms
4. Collecting and synthesizing academic and school performance
5. Use of evidence-based screening tools.
6. Review risk factors, which may influence mental health outcomes.

Question 22

What is functional impairment?

Answer 22

Disability or impairment that has been “defined” as limitations in a person’s ability to perform activities relevant to daily life including the physical, social and personal domains
*Overarching characteristic of the individual that goes beyond the symptoms of the diagnosis

Question 23

Why Assess Functional Impairment? (3)

Answer 23

1. Required by the DSM-IV as a “criterion which must be fulfilled in order to render a diagnosis”
2. Vehicle for tracking treatment outcomes and planning further care
3. Symptom improvement alone does not equal treatment success in psychiatric disorders
   * Does the child have improved functioning?

Question 24

Challenges in Assessing Functional Impairment (5)

Answer 24

1. Defining the concept of functional impairment for patient, provider, and family
2. There is variation in functioning across domains.
3. Impairments may be situation specific.
4. Cultural differences need to be considered.
5. There is variability of impairment found in disorders with specific functional limitations (i.e. neurodevelopmental disorders

Question 25

Functional Impairment History and Physical (2 w/ info)

Answer 25

1. THINK ANTECEDENT, BEHAVIOR, CONSEQUENCE
2. Medical illness can present with psychiatric disease
   a. SLE – Psychiatric evaluation needs to make sure there is no joint pain or blood in the urine
   b. Thyroid disease
3. Order appropriate diagnostics to rule out medical illness
   a. Complete comprehensive metabolic profile, TSH, free T4, and a complete blood count for mood disorder
   b. Drugs screens are not as helpful as we would think
   c. Additional laboratory tests will be ordered when indicated by atypical findings in the history and physical examination

Question 26

Temporal Lobe Epilepsy: Auras (3)

Answer 26

1. Déjà-vu experiences or some gastrointestinal upset.
2. Feelings of fear, panic, anxiety, or a rising epigastric sensation or butterflies with nausea auras present in medial temporal lobe epilepsy.
3. Sense of unusual smell (hippocampal abnormality or a tumor in that area).

Question 27

Temporal Lobe Epilepsy: Overview (4*)

Answer 27

1. Focal impaired awareness (complex partial) seizures can be associated with a fixed stare, impaired consciousness, fumbling with their fingers, or lip- smacking movements that last 30 to 60 seconds.
2. Posture change in an arm
3. Speak gibberish or lose their ability to speak in a sensible manner.
4. Difficulty with the language, particularly if the seizures are coming from the dominant temporal lobe.
   * Must think about neurological or metabolic diseases because they can present with psychiatric manifestations

Question 28

Work-Up For Temporal Lobe Epilepsy (4)

Answer 28

1. Always consider seizure disorders in behavioral problems
2. Temporal lobe epilepsy usually starts after first or second decade
3. MRI of the brain is considered the standard radiology procedure to see the characteristic abnormalities associated with medial temporal lobe epilepsy.
4. An EEG is also essential. The results often show anterior temporal spike or sharp waves, which can occur in both wakefulness and/or sleep.

Question 29

Temporal Lobe Epilepsy: Multigenerational History (3)

Answer 29

1. Genetic factors affect how medications are metabolized.
2. Genetic factors, while yet to be clearly explicated, often play a role in the differential diagnosis of mental illness in children.
3. Children whose parents suffer from affective disorders such as major depression and bipolar disorder are at increased risk for developing such disorders themselves

Question 30

Heritability vs. Recurrence Risk

Answer 30

1. Heritability measures the contribution of genetics (compared to environment) in development of a particular disorder
2. Recurrence risk is the likelihood that a trait or disorder present in one family member will occur again in other family members in the same or subsequent generations

Question 31

Psychiatric Family History (3)

Answer 31

1. Stigma associated with psychiatric disorders
   a. Biases a family history
   b. Parents may neglect to report family members with psychiatric illness
   c. Old notions of environments that “create” psychiatric illness may obscure awareness of genetic contributions
2. Inquire specifically about mental retardation, developmental delay, psychiatric illness, sensory deficits, and suicidality
3. Note age of symptom onset and severity

Question 32

Assessment of Academic and School Performance (5)

Answer 32

1. Records are legally protected by the Family Educational Rights and Privacy Act (FERPA).
   a. Authorization for release of information to be signed by the patient’s parent or guardian.
   b. The signed authorization for release of information is sent, along with the letter requesting the data to the child’s current school. **
   i. Specific as to what they are allowing the school to release (only way to see the IEP)
2. Can be limited to school performance, grades, and official elements of the school record
3. If there has been psychological testing, the authorization for release of information needs to specifically request for the results of psychological testing.
4. If psychological testing is required, school systems typically require a formal meeting, sometimes called an “admission, review, and dismissal” (ARD) in order for a team to determine and request psychological testing for a child by the school system.
5. May make a referral to a private psychologist in order to obtain testing and results

Question 33

Screening surveillance AAP recommendations (3)

Answer 33

1. Developmental surveillance at every well child visit
2. Screening tools specifically at 9, 18, and 30 months (24 months acceptable).
3. AAP endorses standardized reliable (≥80%), well validated scale with a sensitivity and specificity of 70%

Question 34

Screening in primary care (5)

Answer 34

1. All screening measures are not constructed equally
2. Three most widely used screening tools in primary care are:
   a. Ages and Stages Questionnaire (ASQ)
   b. Parents’ Evaluation of Developmental Status (PEDS)
   c. M-CHAT
3. ASQ is more accurate than the PEDS in children over 30 months
4. PEDS is designed to detect a broader array of problems.
   a. However positive or concerning PEDS will be ineligible for EI/ECSE service
5. Higher percentages of children are missed with the PEDS

Question 35

Use of evidence based screening (3)

Answer 35

1. Brief standardized tools: Identify children needing evaluation.
2. While screening is not perfect, studies have identified that children initially identified to have a positive developmental or behavioral screen that are not found to be eligible for services are at high risk and need closer monitoring than children who initially screened negative.
3. At younger ages, parent screens are used to identify parents’ concerns, get a developmental behavioral history and identify developmental and behavioral risk and protective factors