Child Flashcards
Percentage of ADHD types in kids
Mixed 50-75%
Attentive 20-30%
Hyperactive <15%
Percentage of ADHD types in adults
Attentive 50-60%
Mixed 30-40%
Hyperactive 5%
ADHD into adulthood percentage?
60%
REGARDLESS OF RESPONSE TO TREATMENT
Increased risk if family history ADHD, conduct/mood/anxiety co-morbidity, psychosocial adversity
ADHD genetics
Heritability = 75%
RR 2-3 if 1st degree parent
40-60% parents with ADHD will have a kid with ADHD
25% of kids with ADHD have a parent with ADHD
DAT1, DRD4, DRD5, SNAP25
RISK IF BORN IN SEPTEMBER
ADHD neurobiology
Dopamine + norepinephrine
Smaller brain (10%) - especially basal ganglia, frontal lobe, cerebellum
Increased THETA on EEG
Rule-out if suspected ADHD?
Epilepsy, thyroid abnormalities, hypoglycaemia
Percentage co-morbidities kids?
31% ONLY ADHD ODD (40%) Anxiety (33%) Conduct (14%) Tics (11%) Mood (4%)
50% SUD teens have ADHD
Percentage co-morbidities adults?
14% ONLY ADHD (adults have MORE co-morbidities) Anxiety (50%) Alcohol (34%) Drugs (30%) Mood (25%) Panic (15%) OCD (13%)
2 TIMES MORE LIKELY to have SUD
(25% SUD adults have ADHD)
Response rate to psychostimulants?
80%
Which psychostimulant class causes more increased tics?
Amphetamines
Stimulants + Wellbutrin worsen tics in 33%
Atomoxetine is which CYP substrate?
2D6
Atomoxetine mechanism?
Blocks recapture of NE
Useful if co-morbid epilepsy
Intuniv XR
For 6-12 year old
Selective alpha 2 agonist (not as strong as clonidine)
Better tolerated than clonidine
Takes several weeks to work
Watch BP and tachycardia rebound if stopped abruptly
Impact of treating ADHD on future SUD?
Treating ADHD in adolescence decreases or delays substance use but NOT TRUE FOR ADULTS
Gilles de la Tourette co-morbidities?
ADHD (50%)
OCD (20-40%)
Learning d/o
Mood/anxiety d/o
Most common first tic?
Eye blinking
Obscene sx not common <10%
Gilles de la Tourette prognosis?
50-60% remission
Peaks later in childhood and decreases in adolescence
Gilles de la Tourette treatment
1st line = Intuniv, Clonidine
2nd line = Risperdal, Abilify
3rd line = Haldol, Ziprasidone, Fluphenazine, Zyprexa, Tetrabenazine
CLOZAPINE DOES NOT WORK
Clonidine mechanism?
Presynaptic alpha 2 agonism (decreases NE) Can give depression No weight gain, no seizures Hot flash in menopause Hypersialorrhea in clozapine
Clonidine doses?
0.3mg max in kids in divided doses
0.3-1.2mg max in adults in divided doses
INTOXICATION RESEMBLES THAT OF OPIOIDS
INTERACTS WITH BETA-BLOCKERS (they EXACERBATE withdrawal from Clonidine)
ASD co-morbidity?
70% have one mental disorder 40% have at least 2 mental disorders ADHD (50%) ID (30%) Epilepsy (10-35%)
ASD epidemiology
Prevalence 1%
4M : 1F
Girls more likely to have intellectual disability (possibly because those without go unrecognized as ASD)
ASD heritability?
90%
If one child has ASD, 5-10% chance sibling will as well
ASD associated genetic conditions?
Fragile X (x-linked) PKU (recessive) Tuberous Sclerosis (dominant) Neurofibromatosis (dominant) Angelman (dominant) Cri du chat (dominant)
15% have known genetic mutation (not fully penetrant)
Perinatal factors associated with ASD?
Advanced paternal age Perinatal complications Low birth weight First born Premature < 24 weeks
IQ tests
WPPSI 3-7yo (Weschler preschool and primary)
WISC 6-17yo (Weschler intelligence scale for children)
WAIS 17yo and adults (Weschler adult intelligence scale)
Rx in ASD?
NO EVIDENCE FOR SSRI in treating anxiety/rigidity
Risperdal, Haldol, Abilify, Zyprexa
Stimulants not efficacious and poorly tolerated overall (methylphenidate better than amphetamine)
Vineland scale ASD?
Measures adaptive behaviour in 4 areas: communication daily life skills socialisation motricity
Language domains? (4)
Phonology
Grammar
Semantic
Pragmatic
Expressive language d/o co-morbidities?
ADHD (19%)
Anxiety (10%)
ODD/CD (7%)
Childhood onset fluency disorder (stuttering) criteria?
NEED ONE out of 7
INTERJECTIONS IS NOT A CRITERIA
RR 3 if first degree relative has it
65-85% recover; severity at 8yo good prognostic factor
NOT ASSOCIATED WITH LANGUAGE DISORDER
Social (Pragmatic) Communication disorder
Associated with language disorder (unlike stuttering), ADHD, behavioural d/o, learning d/o
Learning disorder risk factors?
Prematurity
Low birth weight
Prenatal NICOTINE
Learning disorder epidemiology?
Prevalence 10% in kids, 4% in adults
2-3M : 1F
Most common cause of language delay?
Intellectual deficit
Enuresis
Must be at least 5 YEARS OLD
Nocturnal 80%, more boys
Diurnal, more girls
Primary at 5 years old, secondary 5-8 years old
Higher risk if father had history than mother
Encopresis
Must be at least 4 YEARS OLD
Usually due to constipation (80%)
Impact of parental separation?
20-25% problems with adaptation in adolescence
33% develop psych problems
More problems than if parent deceased
AN severity?
BMI <18.5 needed for diagnosis Mild >17 Moderate 16-16.99 Severe 15-15.99 Extreme <15
AN-Restrictive specifier?
No recurrent binge/purge x 3 MONTHS
Post-prandial vomiting?
Superior mesenteric artery syndrome
Bulimia timing?
Binge + purge happening on average 1x per week x 3 MONTHS
Bulimia severity?
Mild 1-3 behaviours/week
Moderate 4-7
Severe 8-13
Extreme 14 and more
Binge eating disorder timing?
1x / week x 3 MONTHS
Rumination disorder
Repeated regurgitation x 1 MONTH
Associated with ASD and ID
Treatment with HABIT REVERSAL
(not aversive techniques)
PICA
Persistent eating non-nutritive non-food substances for at least ONE MONTH
CANNOT DIAGNOSE BEFORE AGE 2
Watch out for iron and zinc deficiencies
Associated with ASD, ID, negligence, pregnancy
Other specified eating disorders?
Atypical anorexia nervosa (normal BMI)
Bulimia nervosa of low frequency or short duration
Binge eating disorder of low frequency or short duration
Purging disorder (in absence of binges)
Night eating syndrome (have awareness and recall)
Risk factors for ED?
Female, adolescent, DM1 (RR2), homosexuality (MEN ONLY, protective for women), oriental culture (bulimia ONLY), athletes, family history, dysfunctional family, overprotective family, childhood/parental obesity
Indications for hospitalization in ED?
HR < 40 or > 110 BP < 90/60 (80/50 adolescent) Orthostatic changes Hypoglycemia < 3.3 Hypokalemia < 3 (2.5 adolescent) Hyponatremia < 125 Hypothermia < 36 Dehydrated, organ problems, low PO4, low Mg SI with plan and intetion Weight < 85% healthy weight Low tx motivation NG feeding/supervision (better to give continuous, better tolerated) Familial conflict
AN co-morbidities
MDD 65%
OCD 25% (before ED)
Cluster C traits
Bulimia co-morbidities
MDD 50%
GAD, SAD, OCD, PD
SUD 30%
Cluster B, BPD
AN good prognostic factors
EARLY START (<15 years old)
< 3 years of symptoms
Normal weight within 2 years
Good relationship with parents
AN treatment
FBT 1st line (Structural = Minuchin, Strategic = Haley)
CBT not as good as in bulimia but good after normal weight
Zyprexa (level B)
Risperdal, Seroquel (level C)
SSRIs only work once NORMAL weight
CAREFUL QT PROLONGATION
Weight gain 1kg/week inpatient, 0.5kg/week OPD
Bulimia treatment
CBT first line
IPT, Psychodynamic, Family/Couple, DBT
SSRIs (Prozac 60-80mg, Zoloft, Celexa) NO WELLBUTRIN (risk of seizures)
Refeeding syndrome
Day 4-14
Increased glucose, increased insulin
Increased metabolism (requires PO4, Mg, K)
Increased risk if <70% normal weight and enteral feeding
Careful with carbohydrates
ATP NEEDS PO4
Monitor daily x 5 days then q2d x 3 weeks
Bulimia abnormalities
Metabolic ACIDOSIS with laxatives
Metabolic ALKALOSIS with vomiting (low K, low Cl)
Trousseau + Chvostek sign (hypocalcemia)
Russel (abrasions on back of hand)
Osteoporosis
Normal 1.5 to -1.5
Osteopenia -1.5 to -2.5
Osteoporosis < -2.5
Lab changes in EDs?
INCREASED
Urea, amylase, cortisol, cholesterol, AST/ALT, carotene, T3, GH, CRH
DECREASED
FSH/LH, electrolytes, glucose, T4, vit B12, folic acid, Hg, WBC, Plts, thiamine, niacin, albumin, estrogen/testosterone
ODD criteria?
Lasting 6 months
At least 4 symptoms (out of 8 in categories of angry/irritable mood, argumentative/defiant, vindictiveness), at least one person other than sibling
If < 5yo would expect on most days
If > 5yo would expect at least once per week
Severity depending on number of settings
mild 1 setting
moderate 2 settings
severe 3 or more settings
M>F before adolescence and EQUAL after adolescence
ODD co-morbidities?
ADHD 30-65%
Anxiety 14%
Mood 15-20% (MDD 9%)
Learning and language disorder
ODD prognosis?
33% will develop CD
10% will develop ASPD
66% no longer meet criteria at 3yo
Significant predictor of future mental disorders
CD criteria?
At least 3/15 in past 12 months
At least 1/15 in last 6 months
4 categories Aggression to people or animals Destruction of property Deceitfulness or theft Serious violation of rules
For stays out past curfew and skips school (if < 13yo)
Runs away overnight x 2 or longer period x 1
CD specifiers?
Childhood < 10 yo
Adolescent > 10 yo
With limited prosocial emotions AT LEAST 2 in 12 months
- lack of remorse/guilt
- lack of empathy
- unconcerned about performance
- shallow affect
Severity
CD co-morbidities?
ADHD (36%) Anxiety (22-33%) Mood (15-31%) SUD Dissociation Somatoform (MORE FEMALE PRESENTATION) Learning d/o (30-40%, especially READING and verbal capacity) ID TBI Seizures
CD risk factors?
Young mother Large chaotic family, low supervision Hostility in divorced parents Genetic (hx ASPD or CD) Anxious-avoidant attachment Chronic illness (RR3), neuro illness (RR5) Dense population (urban)
CD neurobiology
DECREASED SEROTONIN (low 5-HIAA in CSF) Less conversion of dopamine to NE (low dopamine B-hydroxylase) Low cortisol in saliva Increased testosterone Slow cardiac rhythm
MZ twins = 50%
DZ twins =25%
CD prognosis?
40% convert to ASPD
(30-50% if childhood onset, 25% if adolescent onset)
GIRLS HAVE WORST PROGNOSIS
CD treatment?
Tx ADHD also decreases sx of CD
Stimulant > Strattera = Intuniv > Clonidine
If no ADHD, Risperdal or Epival
If also impulsivity and tics, 2nd generation AP
DON’T USE BENZO = disinhibition + paradoxical response
DON’T USE LITHIUM, TEGRETOL, SEROQUEL OR HALDOL
IED criteria?
Either
- verbal/physical aggression not resulting in harm 2x/week x 3 months
OR
- behavioral outburst resulting in damage (to property or person) x 3 in last 12 months
Not premeditated or for secondary gains
Have to be AT LEAST 6 YEARS OLD
Usually show REMORSE
IED tx?
Anticonvulsant, Lithium, Antipsychotics, Trazodone, Buspirone
Congenital causes of heart anomalies?
- Trisomy 21
2. Di George
Trisomy 21 risk?
1/1000 if < 45 yo
1/50 if > 45 yo
Non-dysfunction (95% of cases)
Mosaicism (1-2%)
Translocation (2-3%)
Trisomy 21 issues?
Intellectual deficiency
Alzheimer’s dementia (4th decade, increased b-amyloid, 21q21.1)
Epilepsy
Most frequent preventable cause of ID?
Fetal alcohol syndrome
Most common cause of malformation and intellectual deficit due to maternal infection?
Rubella
