Behavioral Medicine Flashcards
1
Q
Child Maltreatment
A
- act inflicted on a child or youth by parent or caregiver
- mucocutaneous (bruise), MSK, visceral, intracranial injury or death
- also defined legally in state statutes
- No socioeconomic, race, or ethnic lines
- physical, sexual, emotional, abuse/neglect
2
Q
When to consider maltreatment
A
- discrepant history
- sudden change in personality (emotional, not necessarily from caregiver)
- Sexualized play that is age inappropriate (sexual abuse): sleep disturbance, appetite change, enuresis, encopresis
3
Q
What is significant about PA and suspected child abuse?
A
mandatory reporters!!
4
Q
ADHD
- 4 characteristics
A
- distractibility
- impulsivity
- hyperactivity
- inattention
5
Q
Subsets of ADHD
A
- predom hyperactivity impulsive (ADHD-HI)
- predom inattentive (ADHD-I)
- Combined (ADHD-C)
6
Q
ADHD
- onset
A
- <12 yo
- 50% meet criteria by age 4
- M>F 2:1
- familial tendency
7
Q
ADHD common comorbidities
A
- Depression
- Anxiety
- ODD
- Conduct Disorder
- LD?
8
Q
DSM-5 criteria for ADHD
A
- <17 must have 6+ inattention and/or 6+ hyperactivity/impulsivity criteria
- must occur often
- must be present <12 yo
- must be present >6 mo
- must be noticed in 2+ settings
- must affect functioning
- must not be explained by another mental disorder
9
Q
AHDH
- explain inattention
A
- careless mistakes
- difficulty sustaining attention
- doesn’t seem to listen, follow through, complete tasks
- avoids tasks that require sustained mental effort
- loses things
- forgetful
10
Q
ADHD
- explain hyperactivity and impulsivity
A
- fidgets
- can’t stay seated
- difficult playing quietly
- “always on the go” or “driven by a motor”
- talks excessively
- blurts answers before question is complete
- can’t wait for turn
- interrupts others
11
Q
ADHD
- what to do if sx only occur in one setting
A
- explore stressors in that setting
- ex. kids undergo extreme stress (divorce, illness, abuse, etc.) mid demonstrate ADHD behavior in that setting
12
Q
ADHD
- History and PE
A
History: school performance
PE:
- baseline weight
- soft neuro symptoms - tic, clumsiness, mixed handed
- hearing and vision check
13
Q
ADHD
- differential
A
- there is a list but i’m not putting it in here :)
14
Q
ADHD
- DX tests
A
- behavioral rating scales: teacher, parents, caregivers
- Labs: lead, EEG if sx indicate absence seizure disorder
15
Q
ADHD
- dx and tx
A
- Dx from multiple angles: survey to parents, teachers, caregivers, etc. as well as psychologist/psychiatrist analysis
- must be Rxed by psychiatrist
16
Q
Eating/feeding disorders
- infants
- toddlers
- school aged
- adolescents
A
- infants are often overfed by parent. 1 oz per hour since last feeding if making bottles
- toddler: growth dependent, might not always eat!
- School aged: willful stubbornness/defiance
- Adolescents: Anorexia nervosa
17
Q
Anorexia nervosa
- DSM5
A
- sig low body weight in context of age, sex, developmental trajectory, physical health
- intense fear of gaining weight or becoming fat or persistent behavior that interferes with weight gain even though at a sig low weight
- disturbance in way experience weight, undue influence of body weight or shape on self-evaluation
- persistent lack of recognition of seriousness of current low body weight
18
Q
AN Dx
A
- be aware of subclinical or atypical AN
- get a good history including exercise and menstrual history
- Complete physical (<85% expected weight)
19
Q
Common physical finding in AN
A
Russell sign: callus on knuckles due to excessive vomiting
20
Q
AN
- treatment
A
- medical
- nutritional
- psychological
- consider admission if outpatient tx is unsuccessful
21
Q
Depression
- covers what disorders
A
- major depressive disorder (MDD)
- dysthymic disorder
- depression associated with bipolar disorder
- adjustment disorder with depressed mood
22
Q
Depression related to what 4 functional impairments
A
- interpersonal
- health (somatic, unhealthy habits)
- work or school
- safety (suicide and other high risk behaviors)
23
Q
Depression risk factors
A
- Fam hx depression, bipolar
- suicide in first degree relative
- prior depressive episode
- Personal hx anxiety, ADHD, learning disability, early loss
- fam dysfunction
- child-caregiver conflict
- negative style of interpreting events and coping with stress
- substance abuse
- trauma
- chronic illness (incl. obesity)
24
Q
Depression common comorbidities
A
- anxiety
- somatization
- disruptive behavioral disorders (ADHD, ODD, CD)
- eating disorders
- substance abuse
- physical/sexual abuse
25
Depression
| - screening
- routine is very important!!
- Dx should be through formal assessment (including risk of suicide) if positive screening
- lots of diff tools
26
Depression
| - management of mild depression
- supportive: educate pt and fam about depression and stress reduction, clinical and community support, management of IDable stresses
- weekly or biweekly PCP visits for 6-8 weeks for monitoring
- if worsens or doesn't improve in 4-6 weeks, additional intervention recommended
27
Depression
| - management of moderate depression
- psychosocial and medical interventions equally effective, combo slightly better than either alone
- 1st line med for adolescents: SSRI
- preadolescent: little evidence for effectiveness of antidepressants, elevated risk of ADR. Refer to child psychiatrist
28
What is risk to use of antidepressants in adolescents and young adults?
Associated with slight increase in risk of suicidal thought and behaviors.
29
First line therapy for premenstrual dysphoric disorder
SSRI
30
Separation anxiety disorder
- developmentally inappropriate
- behavioral inhibition: child approaches unfamiliar situations with distress, restraint, avoidance
- associated with development of anxiety disorders
- Early development of stranger anxiety
- insecure attachment between child and parent
- increased parental anxiety
- parenting style may be excessively controlling and overprotective
- exposure to negative life events or stressors
- fam hx of anxiety or depression
31
Describe separation anxiety
- maladaptive, interferes with normal functioning or becomes overly frequent, severe, persistent
- recurrent excessive distress when separated from home/major attachment figures
- persistent and excessive worry about losing or harm to major attachment figures
- persistent and excessive worry that an event will lead to separation from major attachment figure
- persistent and excessive worry to be alone or without attachment figure
- won't go to sleep without attachment figure, or won't sleep away from home
- nightmares of separation
- physical sx (HA, abd pain, nausea) when separated from attachment figure occurs or is anticipated
- onset <18 yo
- clinically sig distress or impairment
32
Separation anxiety disorder
| - history
- Ask about sleep, esp about nightmares
- Ask if school attendance is impacted
- Duration: transient fears are common, SAD must last >4 weeks
- Ask about stressors:
33
Separation anxiety disorder
| - PE and Dx testing
- PE: None
| - Tests: scales to assist with dx, best have child and parent version
34
Separation anxiety disorder
| - ddx
- GAD
- Social anxiety
- specific phobias
35
Separation anxiety disorder
| - Treatment
Caregiver education:
- Don't prolong goodbye
- Reassure child he/she will be ok
- Don't let child see you are upset
- Don't overdo reunion
36
Separation anxiety disorder
| - treatment if child has extreme difficulties
- start with smaller separations
- use incentives and positive reinforcement
- gradually build to longer separations
37
Social anxiety disorder
| - describe
- marked fear/anxiety of 1+ social situations where exposed to possibly scrutiny by others (must occur in peer situations in children)
- fear will act in way or show anxiety sx that will be negatively evaluated
- social situations always provoke fear/anxiety and are avoided or endured with fear or anxiety
- fear/anxiety out of proportion to actual threat
- usually lasts 6+ months
- causes sig distress
- not attributable to other issues (substance abuse, etc.)
- must specify if performance only: speaking or performing in public
38
Social anxiety disorder
| - epidemiology
7% youths
| F>M
39
Social anxiety disorder
| - dx
- via history, many different surveys
- interview child and parents separately
- core sx: marked anxiety in social situations, fear of negative scrutiny, avoidance of situations must be present
- Distress can be physical: blushing, palpations, trembling, GI upset
- Young children may exhibit periods of mutism in social situation but can talk at home
- older children may appear oppositional and exhibit school refusal
- sx may be exacerbated by env transitions (new school, family moving)
40
Social anxiety disorder
| - treatment
- CBT
- Group therapy
- Family therapy
- Meds: 1st line SSRI (1/2 recommended dose)
41
Oppositional Defiant Disorder (ODD)
| - behavior
- negativistic
- hostile
- defiant
42
Oppositional Defiant Disorder (ODD)
| - cormorbidities
ADHD and ODD/CD co-occur in 30-50% of cases
43
```
Conduct Disorder (CD)
- describe
```
- more severe than ODD
- less common
- habitual rule breaking defined by a pattern of aggression, destruction, lying, stealing, truancy
44
Which of the following is a strong predictor of substance abuse: ODD or CD?
CD IS
| ODD without CD is not
45
```
Conduct Disorder (CD)
- 4 main categories
```
1. aggression to people and animals
2. destruction of property without aggression
3. deceitfulness, lying, theft
4. serious violation of rules
**the slides go into details on each of these, repeat from behavioral health :)
46
```
Conduct Disorder (CD)
- diagnosis DSM
```
- 3 behaviors from 1+ of the 4 categories in last 12 months, 1 behavior must have been in last 6 months
47
```
Conduct Disorder (CD)
- treatment
```
- CBT
- Family therapy
- Parenting education
- carbamazepine?
* * best is to intervene before it gets bad!!
48
Suicide
| - some facts
- 3rd leading cause of death for adolescents and emerging young adults (10-26 yrs)
- mortality tripled 1950s-1990s
- Females attempt 2-4 X males, ingestion
- Males 5 times as likely to die, use more lethal methods
- highest in non-hispanic white and native americans, rate for blacks increasing
- highest rates in gay, lesbian, etc.
- >1/2 involve a firearm
- ~2,000 adolescents die annually, 11X attempt as completed suicides
- 17% youth grades 9-12 reported seriously considering suicide in last year
49
Suicide risk factors
- previous suicide attempt
- social isolation
- substance abuse
- fam hx suicide
- fam hx mental illness/substance abuse
- sexual or physical abuse
- fam conflict, disruptions
- firearms in house
50
Suicide
| - PE
- examine skin for signs of abuse or self-mutilation
51
Suicide
| - prognosis
- 20-50% who attempt will attempt again
| - majority who engage in treatment will disengage after a few visits
52
Munchausen Syndrome by Proxy
- sx of illness are exaggerated, fabricated, induced by caretaker (usu no underlying health disorder in child)
- harm to child via unnecessary tests, meds, surgeries
- sx decrease when child is separated from perpetrator
53
Munchausen Syndrome by Proxy
| - presentation
- no typical
- MC: apnea, seizures, factitious fever, feeding/GI problems, FTT, behavior issues, bleeding, sepsis
- may be mild to fatal
- usu <4 yo
- sig morbidity
54
Munchausen Syndrome by Proxy
| - when to consider?
- SandS incongruous with pt's appearance, seen only when caregiver is present
- dx tests fail to confirm dx
- usual med treatment ineffective
- caregiver is unusually knowledgeable or aggressive in suggesting particular treatments
- red flags: frequent moves, siblings have died/usu med illnesses, seek care at multiple facilities, reluctance to accept less severe dx
55
Munchausen Syndrome by Proxy
| - Dx procedures
- if w/u is consistently normal and sx still described, consider this
- if bleeding, confirm blood is the patients
- Too screen to look for poisoning
- repeated blood/urine cultures with diff orgs suggest intentional contamination
- prevent caretaker from tampering with dx testing
- if separation = sx disappear...
- covert video!!
56
Munchausen Syndrome by Proxy
| - treatment
- team effort
| - child protective services, mental health, law enforcement all have a role
