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Pediatrics > Behavioral Medicine > Flashcards

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
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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
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3
Q

What is significant about PA and suspected child abuse?

A

mandatory reporters!!

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4
Q

ADHD

- 4 characteristics

A
  • distractibility
  • impulsivity
  • hyperactivity
  • inattention
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5
Q

Subsets of ADHD

A
  • predom hyperactivity impulsive (ADHD-HI)
  • predom inattentive (ADHD-I)
  • Combined (ADHD-C)
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6
Q

ADHD

- onset

A
  • <12 yo
  • 50% meet criteria by age 4
  • M>F 2:1
  • familial tendency
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7
Q

ADHD common comorbidities

A
  • Depression
  • Anxiety
  • ODD
  • Conduct Disorder
  • LD?
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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
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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
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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
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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

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12
Q

ADHD

- History and PE

A

History: school performance

PE:

  • baseline weight
  • soft neuro symptoms - tic, clumsiness, mixed handed
  • hearing and vision check
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13
Q

ADHD

- differential

A
  • there is a list but i’m not putting it in here :)
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14
Q

ADHD

- DX tests

A
  • behavioral rating scales: teacher, parents, caregivers

- Labs: lead, EEG if sx indicate absence seizure disorder

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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
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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
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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
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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)
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19
Q

Common physical finding in AN

A

Russell sign: callus on knuckles due to excessive vomiting

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20
Q

AN

- treatment

A
  • medical
  • nutritional
  • psychological
  • consider admission if outpatient tx is unsuccessful
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21
Q

Depression

- covers what disorders

A
  • major depressive disorder (MDD)
  • dysthymic disorder
  • depression associated with bipolar disorder
  • adjustment disorder with depressed mood
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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)
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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
Q

Depression

- screening

A
  • routine is very important!!
  • Dx should be through formal assessment (including risk of suicide) if positive screening
  • lots of diff tools
26
Q

Depression

- management of mild depression

A
  • 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
Q

Depression

- management of moderate depression

A
  • 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
Q

What is risk to use of antidepressants in adolescents and young adults?

A

Associated with slight increase in risk of suicidal thought and behaviors.

29
Q

First line therapy for premenstrual dysphoric disorder

A

SSRI

30
Q

Separation anxiety disorder

A
  • 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
Q

Describe separation anxiety

A
  • 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
Q

Separation anxiety disorder

- history

A
  • 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
Q

Separation anxiety disorder

- PE and Dx testing

A
  • PE: None

- Tests: scales to assist with dx, best have child and parent version

34
Q

Separation anxiety disorder

- ddx

A
  • GAD
  • Social anxiety
  • specific phobias
35
Q

Separation anxiety disorder

- Treatment

A

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
Q

Separation anxiety disorder

- treatment if child has extreme difficulties

A
  • start with smaller separations
  • use incentives and positive reinforcement
  • gradually build to longer separations
37
Q

Social anxiety disorder

- describe

A
  • 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
Q

Social anxiety disorder

- epidemiology

A

7% youths

F>M

39
Q

Social anxiety disorder

- dx

A
  • 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
Q

Social anxiety disorder

- treatment

A
  • CBT
  • Group therapy
  • Family therapy
  • Meds: 1st line SSRI (1/2 recommended dose)
41
Q

Oppositional Defiant Disorder (ODD)

- behavior

A
  • negativistic
  • hostile
  • defiant
42
Q

Oppositional Defiant Disorder (ODD)

- cormorbidities

A

ADHD and ODD/CD co-occur in 30-50% of cases

43
Q 
Conduct Disorder (CD)
- describe
A
  • more severe than ODD
  • less common
  • habitual rule breaking defined by a pattern of aggression, destruction, lying, stealing, truancy
44
Q

Which of the following is a strong predictor of substance abuse: ODD or CD?

A

CD IS

ODD without CD is not

45
Q 
Conduct Disorder (CD)
- 4 main categories
A
  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
Q 
Conduct Disorder (CD)
- diagnosis DSM
A
  • 3 behaviors from 1+ of the 4 categories in last 12 months, 1 behavior must have been in last 6 months
47
Q 
Conduct Disorder (CD)
- treatment
A
  • CBT
  • Family therapy
  • Parenting education
  • carbamazepine?
    • best is to intervene before it gets bad!!
48
Q

Suicide

- some facts

A
  • 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
Q

Suicide risk factors

A
  • 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
Q

Suicide

- PE

A
  • examine skin for signs of abuse or self-mutilation
51
Q

Suicide

- prognosis

A
  • 20-50% who attempt will attempt again

- majority who engage in treatment will disengage after a few visits

52
Q

Munchausen Syndrome by Proxy

A
  • 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
Q

Munchausen Syndrome by Proxy

- presentation

A
  • 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
Q

Munchausen Syndrome by Proxy

- when to consider?

A
  • 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
Q

Munchausen Syndrome by Proxy

- Dx procedures

A
  • 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
Q

Munchausen Syndrome by Proxy

- treatment

A
  • team effort

- child protective services, mental health, law enforcement all have a role

Pediatrics (9 decks)

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