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Applied Behavioral Medicine > Child abuse, obesity, conduct, PTSD, ADHD, Bipolar, Somatic Disorder > Flashcards

Child abuse, obesity, conduct, PTSD, ADHD, Bipolar, Somatic Disorder Flashcards

1
Q

How can you use a non-confrontational approach to assess for and discuss potential abuse with a patient and families

A
  1. open ended questions
  2. show empathy, even if you feel strong that abuse is involved (ie. parents fault)
  3. strategies if faced w/ resistance
  4. give children 12+ choice of who tells the hx
  5. Be upfront
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2
Q

Key info a provider needs to know when assessing for abuse

A
  1. History (of injury) must exist and makes sense
  2. Timeline of injury: when was the last time your baby was normal / walk me through what happened since then
  3. Mechanism of injury
  4. Injury characteristics: shape of bruise, etc
  5. patient’s view of what happened / why are they concerned / what is their definition of rape
  6. hx of abuse in either parent
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3
Q

Be able to determine whether or not a situation requires reporting to social services, the police, etc.

A
  1. Statutory rape: sex below age of consent (laws differ by state)
  2. Injury that does not make sense / potential to be non-accidental
  3. Note: if ever debating on whether or not to report → REPORT
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4
Q

Recognize the key features of Oppositional Defiant Disorder and the typical age associated with it

A

6+ months with 4+ sxs:

  1. Angry/irritable mood (easily annoyed, angered)
  2. Argumentative/Defiant Behavior (defies authority figures, won’t obey rules, purposely annoys others, blames others)
  3. Vindictiveness
  • Mild (1 setting); Moderate (2 settings); Severe (3+)
  • Typical age: young child
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5
Q

Recognize the key features of Conduct Disorder and the typical age associated with it

A

6+ months, at least 3 of 15 traits:

  1. Bullies, threatens others
  2. Start physical fights
  3. Has used a weapon that could cause serious harm or death
  4. Physically cruel to people
  5. Physically cruel to animals
  6. Has stolen while confronting a victim
  7. Forced sexual activity
  8. Fire setting to cause damage
  9. Deliberate destruction of other’s property
  10. Has broken into someone else’s property
  11. Lies to obtain goods or favors
  12. Has stolen items without confronting a victim (shoplifting)
  13. Stays out at night without permission (prior to age 13)
  14. Has run away from home
  15. Truancy: absence from school w/o good reason (prior to age 13)
    * Typical age: teenager (can be younger if fitting traits)
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6
Q

Recognize the key features of Antisocial Personality Disorder and the typical age associated with it

A
  • Same as conduct, just after age 18

* Typical age: over age 18 (common board question)

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7
Q

Traits commonly associated w/ Oppositional Defiant Disorder, conduct, and antisocial personality disorder and NOT w/ behavior disturbances (ADHD, autism, bipolar, depression)

A
  1. Anger, aggression, violence, trouble with authority, disregard rules, blame others
  2. callous, unemotional child
  3. insensitive to punishment
  4. avoid eye contact
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8
Q

Does oppositional defiant disorder always lead to conduct disorder later in life?

A

NO

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9
Q

Identify events that can trigger the development of PTSD

A
  1. War
  2. Fires / tornadoes / traumatic events
  3. Medical issues
  4. Abuse: physical or mental
  5. Parental fighting

Note: not all people react the same to same trauma; some people more vulnerable → women and people who have had previous trauma
*Usually a situation where you feel powerless

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10
Q

List the main categories of criteria in the DSM 5 diagnosis of PTSD

A
  1. Stressor
  2. Intrusion re-experiencing trauma (1+: have to have at least 1 of these sxs)
  3. Avoidance Symptoms: persistent, effortful avoidance of distressing trauma-related stimuli after the event (1+) → often intrusive symptoms lead to avoidance (can be subconscious)
  4. Negative alterations in cognition and mood (2+)
  5. Hyperarousal/Reactivity (2+)
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11
Q

give examples of stressors in PTSD

A
  1. death of loved ones, threatened or actual serious injury, sexual violence
  2. Direct exposure, witnessing, indirect exposure (close relative, family)
  3. Repeated or indirect exposure usually during professional duties (ex: first responders)
    * Does NOT include indirect exposure through media, video games, etc.
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12
Q

give examples of intrusion sx in PTSD

A
  • re-experiencing trauma (1+: have to have at least 1 of these sxs)
    1. Intrusive memories
    2. Traumatic nightmares (people do not want to sleep)
    3. Flashbacks (brief loss of consciousness) – uncontrollably re-living situation
    4. Intense distress after exposure to traumatic reminders
    5. High physiologic reactivity after exposure to trauma-related stimuli
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13
Q

give examples of avoidance sx in PTSD

A

*persistent, effortful avoidance of distressing trauma-related stimuli after the event (1+) → often intrusive symptoms lead to avoidance (can be subconscious)

  1. Trauma related thoughts or feelings
  2. Trauma related reminders (people, places, activities, etc.)
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14
Q

give examples of negative alterations in cognition and mood in PTSD

A

(need 2+)

  1. Inability to recall event details (dissociative amnesia – not recalling trauma)
  2. Persistent negative beliefs about self and world (bad, unsafe, scary)
  3. Persistent distorted blame of self or others for event and consequences (guilt, blame)
  4. Lack of interest in pre-trauma activities (anhedonia)
  5. Feelings of alienation (detachment)
  6. Flat or negative affect
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15
Q

give examples of hyperarousal/reactivity in PTSD

A

(2+)

  1. Irritability/aggressiveness
  2. Self-destructive/reckless behavior
  3. Hyper-vigilance
  4. Exaggerated startle response
  5. Problems concentrating / problems sleeping
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16
Q

What is the difference between acute stress disorder and PTSD

A

acute stress disorder (<1 month)

PTSD (>1 month)

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17
Q

___ is called the “great imitator”

A

PTSD

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18
Q

Explain how PTSD can affect functioning in key parts of the brain

A
  1. Reptilian Brain: homeostasis, endocrine system (brainstem – keeping things going; no thought processes)
  2. Mammalian System (limbic system; amygdala): emotional and memory regulation (primitive)
  3. Emotional Brain: combo of the above, purpose is to look out for welfare, use hormones to communicate, initiate fight/flight/freeze
  4. Neocortex (prefrontal cortex): logic, planning, understanding, choice, empathy (large and unique to humans – thinking part of brain)
  5. Thalamus (“cook”): messenger b/t neocortex and mammalian; which processes what is happening and sends appropriate messages to the amygdala and frontal cortex
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19
Q

In PTSD, the __ and __ goes up (no rational thinking behind initial emotions) and __ and __ go down

A

Mammalian and emotional brain

Neocortex and thalamus

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20
Q

Explain several ways in which an fMRI can look abnormal when a person is asked to recount a traumatic event

A
  1. During flashback (husband): right-side of brain is active (related to emotion and intuition); amygdala very active
    * pre-frontal cortex (logic, speech) is inactive
  2. During flashback (wife): decreased activity in all area of brain (vital signs did not change) – frozen
    - Completely dissociated → freeze response; depersonalization; cut self off from these emotions (but also from normal, happy emotions)
    - Have little emotion when they talk about the experience (often trauma in past)
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21
Q

what is the number 1 preventative measure and tx for PTSD

A

support

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22
Q

What meds can be used for PTSD

A
  1. SSRI’s
  2. Prazosin (alpha-adrenergic blocker (antihypertensive) – watch for hypotension)
  3. beta-blockers: calm physicologic reactivity
  4. Benzos
  5. Atypicals (many SE, not recommended typically)
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23
Q

What are ways to treat PTSD

A

1 preventative measure and treatment for PTSD is support

  1. Meds
  2. EMDR (eye movement desensitization and reprocessing)
  3. Psychotherapy
  4. Mindfulness, body therapy (Message), animal therapy
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24
Q

How can Prazosin help PTSD

A
  1. Used specifically for nightmares

2. Dosing: begin with 1-2 mg at night, some studies suggest up to 25 mg effective

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25
Q

How can BB help PTSD

A
  1. calm physiologic reactivity
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26
Q

How can Benzos help PTSD

A

possibly if use can be prn for specific trigger

*use cautiously

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27
Q

How can EMDR help PTSD

A
  1. non-medication; worth a try
  2. Simulates eye mov’t that happens during REM sleep (natural healing process); asked questions during this mov’t about stressors or traumatic event
  3. 1-12 sessions depending on seriousness of condition
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28
Q

How can Mindfulness, body therapy (message), and animal therapy help PTSD

A
  1. People with PTSD usually over or under react → often leads to turning things off completely
  2. Animal therapy: involves communicating with animals as well as therapeutic riding (horses)
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29
Q

Describe the core symptom of ADHD in pediatrics

A
  1. Irritability,
  2. impulsivity,
  3. mood swings
  4. inattention, hyperactivity
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30
Q

ADHD is impairment in __, ___, and __

A

attention, impulse control, hyperactivity

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31
Q

Causes of ADHD

A
  • prevalence rates are rising (possibly more diagnosed)
    1. Video games / screen time:
  • “Spongebob study” Spongebob v. Cayou → quality and quantity of programming: 20 mins post watching, kids watching Spongebob had ADHD sx’s.
  • Kids spend more time in front of screens than in school!
    2. Change in societal expectations: “everyone” should do well in school / go to college
    3. Diet: no data for this (doesn’t mean that individuals may not do well w/ restricting certain items)
    4. Genetic link: 45-50% (like high blood pressure!)
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32
Q

Recognize the most common chief complaints parents give about a child who might have ADHD

A
  1. irritability
  2. impulsivity
  3. mood swings
  4. inattention, hyperactivity
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33
Q

the statistics on prevalence of ADHD in pediatrics

A
  1. 10% of PEDS primary care visits - COMMON
  2. Overall 8%: boys 13.2, girls 5.6
  3. Prevalence climbs as age increases (likely discovering more cases)
  4. Greater prevalence in south-east (likely diagnostic bias – different parts of country are open to and seek this dx)
    - Psychiatric diagnoses: be careful (subjective) → diagnostic bias more common in psych disorders
  5. 1/3 of kids just grow out of it (2/3 needs meds)
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34
Q

explain the neuro-pathophysiology related to ADHD and how it corresponds to the core symptoms

A
  1. Poor impulsivity (frontal lobe): jump right into a flight every time you are offered one (when other kids may shut down and choose not to flight) → not that these kids have more negative thoughts, just can’t suppress them
  2. Dorsolateral Prefrontal Cortex: Little area in brain that is “where your mother lives”, “braking system of brain” → this part of the brain acts up less with ADHD
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35
Q

ADHD stimulate what part of the brain

A

Dorsolateral prefrontal cortex: : judgment, impulse control, motivation, attention

  • But also can cause anxiety
  • done developing by age 26
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36
Q

Be aware of the possible risk factors associated with the development of ADHD

A
  1. Decreased school performance
  2. Socialization interrupted (do not have friends, excluded, disliked)
  3. Erodes family relationships (tough/exhausting on parents)
  4. Self image: you’re the bad kid, dumb kid (need to tx)
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37
Q

various treatments options for ADHD in pediatrics and their effectiveness

A
  1. Behavioral therapy- works but small effect size and difficult to implement (motivation is not there)
  2. Meds/stimulants (VERY EFFICACIOUS, effect size =1!)

**therapy VERY questionable in ADHD (vs. mood disorders where combo is best)

38
Q

What are side effects of stimulants used in ADHD

A
  • generally well tolerated
    1. Weight loss (dec. appetite)
    2. Stature (possibly ½ cm of adult height if on for long time)
    3. Insomnia: since stimulant
    4. Affective blunting: like a zombie (don’t feel much of anything)
39
Q

Describe the algorithm for ADHD tx

A
  1. Methylphenidate: Concerta
  2. Switch to Mixed salt amphetamine (adderall, regular, XR, Vyvanse**)
  3. Add Clonidine for sleep, tics, or impulsivity
  4. add guanfacine (if anxious)
  5. add atypical (for rage)
  6. Try Straterra or Wellbutrin (if pts don’t want stimulants or Strattera for autistic kids)
  7. Try alternative delivery (ie. patch for rapid metabolizers)

*when stimulants wear off, symptoms may be even worse – add a small dose in the afternoon to compensate

40
Q

Describe the Methylphenidate drug of choice for ADHD

A

Concerta (methylphenidate ER - sustained release) → causes ascending blood levels which is what stimulates brain the best (dose 0.5-2 mg/kg)

*Begin here in kids b/c lower side effects than mixed salt amphetamines

41
Q

Side effects of mixed salt amphetamines

A
  1. disturb sleep more
  2. higher anxiety
  3. better in adults
    dose 0.5-1.5mg/kg

*Vyvanse less likely to be abused because has to go through liver to be activated- lower street value

42
Q

Side effects of clonodine

A

anti-hypertensive (reverses effect of stimulant)

43
Q

What type of drug is guanfacine

A

a-agonist

44
Q

Side effects for atypicals (used in ADHD)

A
  1. wt. gain
  2. cholesterol
  3. blood sugar problems
45
Q

What ADHD med works well in Autistic kids

A

Strattera

46
Q

List the 3 key symptoms (CC) of Bipolar Disorder in pediatrics

A
  1. PROLONGED rages (hours; ex: girl tore sofa apart with a knife over a period of 3 hours)
  2. Euphoria: not normal, extreme (does not go away in normal time – lasts for days)
  3. Grandiosity: borders on psychotic (e.g. jump off roof and fly)
47
Q

Describe the DIGFAST for bipolar

A
  1. Distractibility: racing thoughts
  2. Indiscretion/Impulsivity: spending, sex, high risk activities
  3. Grandiosity: inflated self-esteem, poor insight
  4. Flight of ideas: jumping from topic to topic
  5. Activity: high energy, agitation or restlessness; can be very fun
  6. Louder, faster, moving more, intense goal directed activity
  7. Sleep: decreased need or ability
  8. Talkativeness: pressured speech (louder, faster, intense)
48
Q

Bipolar in kids → effects on development:

A
  1. Dec. school performance
  2. Socialization interrupted
  3. Isolation
  4. Erodes family relationships
  5. Inc. medical usage and costs (up to 50%) – non-psychiatric
49
Q

Comorbidities of bipolar

A
  1. Anxiety: 50% (more in kids)
  2. Substance abuse: 48% (3/4 recover – abstinence for 5 yrs)
  3. ADHD: 10-20% (worse course of illness and trouble; most adults wi/bipolar have been dx as ADHD in childhood)
    - Could ADHD in childhood be indicators of bipolar later in life)
50
Q

Describe ways to treat bipolar

A
  1. social rhythm therapy (same routine, sleep is VERY important)
  2. Meds
    - Atypicals
    - mood stabilizers
    - antidepressants (do NOT tx bipolar depression)
51
Q

Describe the use of atypicals for bipolar

A

*First line use in peds

52
Q

give examples of atypical used in bipolar

A
  1. Abilify (1st line choice in peds– least SE)
  2. Risperdal
  3. Seroquel
  4. Geodon
  5. Zyprexa (DONT USE! ANYMORE)
53
Q

Side effects/cons of Risperdal (used in bipolar)

A
  1. elevates prolactin → modifies hormone profile for a hormone that has >300 receptors
  2. Weight gain
  3. metabolic consequences?
54
Q

Side effects/cons of Seroquel (used in bipolar)

A
  1. wt. gain
55
Q

Side effects/cons of Geodon (used in bipolar)

A
  1. BID

2. have to take w/ large fatty meal (500 calories)

56
Q

Side effects of Zyprexa (used in bipolar)

A
  1. malpractice (?) → GET KIDS OFF;
  2. massive wt gain,
  3. DM, etc.
    * *(mean wt gain at 12 wks is 15 lbs)
57
Q

What mood stabilizers are used for bipolar

A
  1. Lithium (1st line choice in adults)– best by far
  2. Depakote
  3. Tegretol
  4. Trileptal
  5. Lamictal
58
Q

SE/cons of Depakote (used in bipolar)

A
  1. wt gain
59
Q

SE/cons of lithium (used in bipolar)

A

BEST CHOICE

1. may see slow degredation of kidney fxn

60
Q

SE/cons of Tegretol (used in bipolar)

A

(anticonvulsant)

1. self inducing metabolism (difficult to mange-DDI)

61
Q

SE/cons of Trileptal (used in bipolar)

A

2 neg trials
2. no use in kids (cochrane)

*if on and working dont mess w/ it

62
Q

SE/cons of Lamictal (used in bipolar)

A

no mania coverage (not ok for bipolar); helps w/ depression

63
Q

Describe the use of antidepressants in bipolar

A
  • DO NOT treat bipolar depression
    1. May cause switching (make manic) → this won’t happen if have mood stabilizer on board
    2. Role in anxiety → ok to sue for anxiety if on mood stabilizer to prevent switch from depression to mania
64
Q

Algorithms for Bipolar: PEDS v. Adults

A

1st: be sure it is bipolar disorder (and not rage disorder)
- Once have this dx, have for life

  • Kids: atypicals are 1st line (Abilify)
  • Adults: mood stabilizers are 1st line (lithium, Depakote
65
Q

Know the posited risk factors for the development of Bipolar Disorder in pediatrics - Causes

A
  1. Genetics / heritability: 45-50%
    - 1st order relative w/ bipolar (mom/dad): 10% more likely to get disease (90% that he doesn’t – still rare)
  2. Family strife: high affective environment turns these genes on
  3. Friend strife

*becareful of parent that comes in saying child has bipolar bc they have bipolar– could be ADHD

66
Q

Be able to identify the characteristics of Disrupted Mood Dysregulation Disorder (DMDD) and explain how it is similar to and different from Bipolar Disorder

A

DMDD:

  • Rage disorder; children who are angry and irritable all the time
  • Persistent anger and irritability
  • Debilitating rage
    • Childhood disease - gets better w/ frontal lobe development
  • Treatment: often like BPD (bipolar disorder) but they outgrow
    - Clonidine
    - Abilify
67
Q

Explain how the (Adverse Childhood Experiences) ACE’s study came about

A
  1. • Dr. Vince Felitti (Chief of Kaiser’s Department of Preventative Medicine) was stumped by why 50% of the obesity clinic’s patients dropped out, even when they were successfully losing weight – 1990s
  2. Decided to do face-to-face interviews with some of the participants and mistakenly asked “how much did you weigh when you first had sexual intercourse instead of how old were you?”
  3. “Overweight is overlooked and that’s the way I need to be…”
  4. Dr. Vince Felitti joined forces with Dr. Anda from the CDC to perform the ACEs survey on 17,421 Kaiser patients
68
Q

Conclusions from the ACE study

A
  1. Gravest and most costly public health issue in the United States: child abuse
  2. Overall costs exceed those of cancer or heart disease
  3. Eradicating child abuse in America would reduce the overall rate of depression by more than half, alcoholism by two-thirds, and suicide, IV drug use, and domestic violence by three-quarters
69
Q

Describe the correlation between ACE’s scores and subsequent morbidity and mortality

A

Increasing ACE score: inc. in a lot of morbidity (obesity, depression, risky behaviors, etc.) and mortality

  • Parents tend to “pass” their ACE’s to their children
  • Note: women 50% more likely to have an ACE score >5
70
Q

Recognize the ways that physical symptoms can be associated with a history of trauma or abuse

A

Physical manifestations of stress (from trauma / abuse):

  1. Insomnia, headaches/migraines, GERD, GI pain or upset, weight loss or gain, MSK pain (back, neck, shoulders), acne, fatigue, hair loss
  2. Elevated LFT’s, URIs, canker sores, influenza
  3. Anxiety or panic attacks
71
Q

Explain to a patient or relative why victims of incest or sexual assault may appear “numb” or not be able to discern future threats to themselves.

A
  1. This is a coping mechanism; often feel shame
  2. Also, humans born with short serotonin alleles (associated with mood issues and aggression) found to have higher rates of depression ONLY if they have history of child abuse/neglect
  3. Importance of nature AND nurture
72
Q

List and recognize the demonstrated long-term consequences of incest (sexual contact within family)

A
  1. Experiment by Putnam and Trickett: followed group of 84 victims and 84 controls over 20 years
    - Cortisol levels actually found to drop in victims of incest
  2. Abused girls less likely to develop close friendships, puberty starts 18 months earlier
  3. Cognitive deficits, high school drop-out, depression, obesity, self-mutilation, major illness
73
Q

Explain what the “Still Face” experiment demonstrates about the importance of connection between a child and its primary caregiver

A
  • Importance of connection between infant and primary caregiver (infant gets upset when caregiver shows lack of emotion towards them → almost scarred, feel stress, get upset)
  • Children use this connection to feel safe and confident, which allows then to develop confidently into adulthood
74
Q

According to Bowlby theory, ___ is paramount in normal growth and development

A

Infant attachment with mother

75
Q

According to Bowlby theory, attachment creates a sense of security in early childhood that affects the __, __, and __

A

sense of self and relationship to the caregiver and the rest of the world going forward

76
Q

A child who’s working model of itself is:

  1. positive and loved
  2. unloved and rejected
  3. angry and confused

will show what type of behavior

A
  1. positive and loved: secure
  2. unloved and rejected: avoidant
  3. angry and confused: resistant

*based off John Bowlby theory

77
Q

Mary Ainsworth: The Strange Situation, studied the types of attachement between children and primary caregivers and came up with 3 classifications:

A
  1. Secure attachment
  2. Insecure ambivalent (resistant) attachment
  3. Insecure avoidant attachment
78
Q

What type of attachment?

-Baby seems unaffected by mom leaving, stranger entering, mom coming back

A

Insecure avoidant attachment

79
Q

Insecure avoidant attachment typically has what type of home experience and how do they respond when distressed

A
  • Home experience: poor / lack of response to child’s needs
  • If you’re distressed, try to hold it together (learn to deal w/ distress on own) – be tough

*stiff upper lip (may be seen in different cultures)

80
Q

What type of attachment?

(upset when mom leaves, better quickly when she returns):

  • Stranger enters room, stranger tries to interact with child, mother leaves (baby follows and then cries)
  • The reunion: baby calms quickly
  • Mom leaves (leaving child alone), stranger enters to console (baby still cries), mom returns (baby calms almost immediately) → key part is how baby reacts when mom returns
A

Secure attachment

81
Q

what does secure attachment show about home environment and how the child will grow up

A
  • What this shows: parent is available and loving and baby feels deserving of that love. consistent and appropriate response to child’s needs
  • Future: children get along better with peers, resolve conflict, etc.
82
Q

What type of attachment?

  • Baby seems interested in stranger, not upset when mom leaves (with stranger), upset when mom and stranger leave (when alone), stranger able to comfort baby (usually not the case), baby uninterested when mom returns and cries when stranger leaves (even though -Mom’s back, and I am still not ok
  • A lot of mixed up emotion
A

Insecure ambivalent (resistant) attachment

83
Q

What does Insecure ambivalent (resistant) attachment say about the home environment

A

inconsistent response to child’s need

84
Q

What is disorganized attachment

A
  1. Parents have provided terrifying experiences for infant (ether by looking terrified themselves or by actually terrifying child through abuse)
  2. Brain is going in two ways:
    - I am afraid, go to my attachment figure
    - I am afraid, I need to move away from this person (my attachment figure)
85
Q

What are consequences of disorganized attachment

A

ability to regulate emotions is compromised down the road, trouble with intimate relationships, misinterpret people and their reactions

  • In our own brains, we develop meaning behind actions (hand raised may mean something different to different people: saying hi, asking question, about to be hit)
  • Impulse and actions: flee (run), freeze (helpless), fight

**frightening (desire for attachment yet fear)

86
Q

Describe the reaction to mother leaving for:

  1. secure attachment:
  2. Insecure (ambivalent/resistant):
  3. insure (avoidant):
  4. Disorganized:
A
  1. secure attachment: distressed
  2. Insecure (ambivalent/resistant): distress
  3. insure (avoidant): NO distress
  4. Disorganized: not consistent
87
Q

What type of attachment?

Interaction w/ stranger: ok when mom is there. not able to be comforted by stranger when mother is gone

Response to mother returning: easily comforted and back to baseline. Once again eager to explore w/ mom as “safe baseline”

A

secure

88
Q

What type of attachment?

Interaction w/ stranger: avoidant of stranger whether mom there or not

Response to mother returning: shows signs of continued stress. may be angry/push mother away. less likely to explore

A

Insecure (ambivalent/resistant)

89
Q

What type of attachment?

Interaction w/ stranger: not consistent

Response to mother returning: contradictory behavior, including freezing, seeking then rejecting parent (fight back)

A

Disorganized

90
Q

What type of attachment?

Interaction w/ stranger: fine w/ stranger. able to be comforted by stranger while mom is gone

Response to mother returning: no interested in mothers return

A

insecure (avoidant)

Applied Behavioral Medicine (6 decks)

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