Child Psychiatry - Ryst

Question 1

What are some characteristics of a child assessment?

Answer 1

1. usually occurs within a family context
2. ideally interview the child together and separately from the family
3. requires detective work and integration of data from separate sources

Question 2

Things to ask about in a child assessment.

Answer 2

1. behavioral difficulties
2. functional impairments
3. subjective distress
4. stressors and environmental factors
5. adverse impact on development
6. want to know how they are functioning at home with the family, with peers, at school and in their extracurricular activities

Question 3

What sorts of things would you want to ask about for the physical development and medical history in a child assessment?

Answer 3

1. height, weight and vitals - especially important for prescribing medications and assessing development
2. gross motor development
3. coordination, activity status
4. eating, sleeping and toileting status
5. chronic and acute illnesses
6. seizures , head injuries
7. allergies, vision/hearing impairment
8. exposure to lead or toxins
9. current and past medications
10. sexual developments

Question 4

What are some other domains that are important to ask about in a child assessment?

Answer 4

1. School - want to know their progress, how often are they absent, are they in special education classes etc.
2. emotional development and temperament
3. substance use
4. peer relations
5. family relations
6. trauma

Question 5

What sorts of things are you looking for with the family interview portion of the child assessment?

Answer 5

1. How does the parent talk about and describe the child?
2. discipline practices
3. parental attachment
4. parental attitude towards child
5. goodness of fit between parental personality type and child personality type
6. socio-cultural factors
7. communication styles

Question 6

Describe some characteristics of the child interview portion of the child assessment.

Answer 6

1. Requires flexibility and creativity—must use techniques appropriate to child’s developmental level (not the same as an adult interview).
2. Can use interactive play, projective techniques or direct discussion.
3. Perform developmental mental status.
4. Ask about child abuse.
5. Establish alliance with the child.

Question 7

What are some things you should consider during the child assessment?

Answer 7

1. does the child need psychological testing
2. does the child need medical evaluation
3. does the child need educational assessment
4. does the child need speech and language evaluation
5. is there a need for social service referral or evaluation of the home environment

Question 8

After the interviews are done in the child assessment, what are the next steps?

Answer 8

1. Come up with a diagnostic formulation. This is an evaluation of how the child developed, what are the main issues and what are the child’s strengths that may be used to help in treatment of the issues. Should include all the pertinent findings that lead to a diagnosis.
2. communicate the findings and recommendations to the family

Question 9

Describe some principles of child treatment.

Answer 9

1. Everything happens within a developmental context.
2. Goal is to promote continued, healthy, optimum development
3. Maximize the child’s adjustment in these domains: home, friends, school, play.
4. Multi-modal treatment usually the best. Medication alone is usually not appropriate treatment.
5. Must weigh the risks and benefits of treatment (or no treatment.) Sometimes no treatment is more hurtful and risky than the effects of medications.

Question 10

What are some of the tools that psychiatrists can use in treatment of children?

Answer 10

1. pscyhotherapy
2. medications
3. advocacy - can advocate for kids with school, help them get social resources and advocate with family members who may not understand

Question 11

What are some components of psychotherapy?

Answer 11

1. play therapy
2. interpersonal psychotherapy
3. cognitive-behavioral therapy - not really appropriate for those under age 7 or so
4. parent guidance therapy
5. family therapy

Question 12

What are some considerations for using medications in treating psychiatric disorders in children?

Answer 12

1. medication use is ‘off label’ - there are no meds indicated for use in children
2. kids are not little adults - therapeutic and adverse effects vary by developmental stage and by developmental disorder
3. kids metabolize drugs more quickly than adults - more mg/kg are prescribed for kids than adults
4. Tricyclics are not effective in children due to differences in their NE transmission system
5. meds are appropriate for kids - but should be used with caution. Not using meds could lead to progression of disease and disrupted development

Question 13

What is oppositional defiant disorder?

Answer 13

1. A recurrent pattern of negativistic, hostile and defiant behavior
2. Must have at least four of the following for at least six months:
   Often loses temper
   Often argues with adults.
   Often actively defies or refuses to comply with adults’ requests or rules.
   Often deliberately annoys people.
   Often blames others for mistakes or misbehavior.
   Often touch and easily annoyed.
   Often angry and resentful
   Often spiteful and vindictive

Question 14

What is conduct disorder?

Answer 14

1. Violation of the rights of others and age-appropriate social norms.
2. Must have at least three symptoms in the last 12 months, with at least one symptom in the last 6 months.
3. symptoms include the following:
   Bullying or threatening others.
   Fighting
   Using a weapon that can cause serious physical harm.
   Physically cruel to animals.
   Physically cruel to people.
   Stealing while confronting a victim.
   Forcing someone into sexual activity.
   Fire setting.
   Destroying property.
   Breaking into a house, building or car.
   Frequent lying or “conning.”
   Stealing without confronting a victim.
   Staying out late despite parental prohibitions.
   Running away from home.
   Being truant from school.

Question 15

The majority of kids with oppositional disorders do not go on to adult criminal behavior but some can move from ODD to CD to adult criminal behavior. How are the subset of these kids identified for early intervention?

Answer 15

1. CD kids can be diagnosed with a specifier called - ‘with limited prosocial emotions’
2. Data have identified a subgroup of children with CD that display a lack of guilt and empathy, lack of concern over performance in important activities, and shallow affect. Compared to other children with CD, this subgroup appears to have more severe symptoms, a more stable course, and greater levels of aggression. Addition of this specifier will inform the development of specialized treatments separate from those used with other CD populations

Question 16

What is the prevalence of ODD?

Answer 16

1. 2-16%

2. twice as common in males

Question 17

What is the prevalence of CD?

Answer 17

1. 9% of males less than 18
2. 2% of females less than 18
3. males with early onset CD are much more likely to show aggressive symptoms

Question 18

What is the association between CD and ODD and ADHD?

Answer 18

1. onset of CD is particularly early in ADHD boys (these are often comorbid)
2. CD boys with ADHD have a worse outcome than those without ADHD - important because ADHD can be treated
3. early onset of CD is often preceded and predicted by persistent ODD symptoms

Question 19

What are some symptoms associated with ODD that are predictive of future CD diagnosis?

Answer 19

1. Single syx of cruelty to people and weapon use were best predictive of subsequent diagnosis of CD in one study.
2. In another study, physical fighting + ODD were best predictors of the onset of CD.
3. Proactive aggression seems to be worse than reactive aggression. Overt disruptive behavior may be worse than covert disruptive behavior.
4. severity of symptoms are highly predictive
5. Age- and gender-atypicality are prognostic of later outcome:
   In younger kids, syx of cruelty, running away and breaking into a building most predictive of CD.
   For girls, fighting and cruel behavior are atypical symptoms and most predictive of CD.

Question 20

The presence of early Anti-Social Personality or psychopathy-related symptoms (egocentricity, callousness, manipulativeness) may predict what?

Answer 20

The eventual development of Anti-Social Personality Disorder.

Question 21

Describe some frequent comorbidities among psychiatric disorders in children.

Answer 21

1. ADHD: earlier age of onset of CD, more physical aggression, more persistent CD.
2. Anxiety: Youths with CD are increased risk for anxiety disorders.
3. Mood Disorders: Joint presence of these two increases risk of substance abuse and suicide.
4. Substance Abuse: Reciprocal relationship: each exacerbates the other.
5. Learning Disabilities: (Language problems, memory, sensory integration, executive function deficits, academic deficiencies, low intellectual functioning.)

Question 22

Conduct disordered youth are more likely in adulthood to what?

Answer 22

1. Have greater psychiatric impairment: Anti-social Personality Disorder, alcohol and drug abuse, anxiety, somatic complaints, psych hospitalization.
2. Have higher rates of driving while intoxicated, criminal behavior, arrest records, convictions and period of time spent in jail.
3. Be less likely to be employed, shorter employment history, lower status jobs, frequent job changes, lower wages, more dependence on welfare, serve less frequently and perform less well in the armed services.
4. Have higher rates of school drop-out, lower academic achievement.
5. Have higher rates of divorce, remarriage and separation.
6. Less contact with relatives, friends and neighbors, less church involvement.
7. Higher mortality rate, higher rate of hospitalization for physical problems.

Question 23

Treatment of disruptive behavior disorders is successful when?

Answer 23

Interventions address multiple needs from multiple domains and involve the parents.

Question 24

What components are part of successful treatment of disruptive behavior disorders?

Answer 24

1. parent-directed component
2. social-cognitive skills training 3. academic skills training
3. proactive classroom management and teacher training.

Isolated, individual treatments don’t work!

Question 25

Are there FDA approved medications for treatment of disruptive behavior disorders?

Answer 25

No.

Question 26

What are some meds that are used clinically to treat disruptive behavior disorders?

Answer 26

1. mood stabilizers 2. typical and atypical antipsychotics 3. Clonidine and the stimulants may help to decrease aggression, reduce emotional reactivity and moderate levels of emotional arousal. 4. treatments are not great at this time but if there is a treatable comorbidity such as ADHD then this can help

Question 27

What are some well-established psychosocial treatments of disruptive behavior disorders?

Answer 27

1. For younger children (ODD): Parent Management Training: Trains parents to interact with child in a way that promotes pro-social behavior. Focuses on antecedents and reinforcement. Combination of parent and child training is superior to working with parent alone. PCIT (Parent-child Interaction Training): Studied in RAPC trials. First phase: Parents trained in nondirective play skills to alter quality of parent-child interactions. Second phase: Parents taught to give clear instructions, praise for compliance, time-out for noncompliance. 2. MST (Multisystemic therapy): Addresses risks at the individual, family, peer, school and neighborhood level. Treatment is intensive and addresses therapeutic barriers such as parental substance abuse, parental psychopathology, marital conflict, associations with delinquent peers, poor school performance and deficient problem-solving or perspective-taking skills. Very expensive and hard to do.

Question 28

Why have mood disorders been historically misunderstood and misdiagnosed?

Answer 28

1. Children’s inability to express emotions verbally,and tendency to present with somatic syx and complaints. 2. Tendency of parents and teachers only to notice obvious, external symptoms (disruptive behaviors.) 3. Bipolar Disorder difficult to diagnose in children due to developmentally different presentation in children as well as significant symptoms overlap with ADHD.

Question 29

What is the diagnostic criteria for childhood depression?

Answer 29

Same DSM5 diagnostic criteria as for adults, except: 1. For children and adolescents, can have irritable mood instead of depressed mood. 2. Failure to make expected weight gains is equivalent to weight loss. 3. For Dysthymic Disorder (new name = Persistent Depressive Disorder) : mood can be irritable rather than depressed, and duration must be at least one year (not two).

Question 30

What is the difference between irritable mood vs depressed mood?

Answer 30

Depressed mood is more about internal feeling and is described by the patient (hard for children) whereas irritable mood is something that can be observed.

Question 31

What are some differences in symptoms between adults and children/adolescents in depression?

Answer 31

Phenomenological differences in children: 1. Somatic complaints, psychomotor agitation, mood-congruent hallucinations more prevalent. 2. Can also manifest as separation anxiety, phobias, and behavioral problems. 3. Look for deviations from developmental trajectory: school failure, withdrawal from peers, lack of interest in prior activities. Phenomenological differences in adolescents: 1. Can present as antisocial behavior, substance use, restlessness, grouchiness, aggression, withdrawal, school or family problems, feelings of wanting to leave home, feelings of not being understood, loved or approved.

Question 32

Describe the criteria for juvenile bipolar disorder.

Answer 32

1. Same DSM criteria as for adults. 2. Now generally accepted that clinical presentation of mania in children is atypical by adult standards: - More frequently “mixed” states (mania + depression) - “Rapid cycling” - Chronic and continuous rather than acute and episodic - Seldom associated with euphoria, usually prominent irritability with affective storms, prolonged aggressive temper outbursts, emotional lability - In older children (> age 9), euphoria, elation and grandiosity more common

Question 33

What is an affective storm?

Answer 33

Extreme emotional outburst out of proportion to the situation or triggering event.

Question 34

What are some associated symptoms that occur with juvenile bipolar disorder?

Answer 34

1. Decreased need for sleep 2. Rapid speech, talkativeness 3. Distractibility, racing thoughts, tangentiality 4. Hypersexuality - (not really sex but other behaviors like masturbation or removing clothes in public etc.) Not really seen in other disorders, need to make sure not a result of abuse 5. Increased goal-directed activity 6. Impulsivity 7. Abnormal thought content, paranoia

Question 35

What is a new diagnosis added to DSMV that is meant to capture those who have some symptoms of bipolar but don't meet criteria?

Answer 35

Disruptive mood dysregulation disorder or DMDD. Rationale: This addresses the disturbing increase in pediatric bipolar diagnoses over the past two decades, which is due in large part to the incorrect characterization of non-episodic irritability as a hallmark symptom of mania. DMDD provides a diagnosis for children with extreme behavioral dyscontrol but persistent, rather than episodic, irritability and reduces the likelihood of such children being inappropriately prescribed antipsychotic medication. These criteria do not allow a dual diagnosis with oppositional-defiant disorder (ODD) or intermittent explosive disorder (IED), but it can be diagnosed with conduct disorder (CD). Children who meet criteria for DMDD and ODD would be diagnosed with DMDD only.

Question 36

Describe the epidemiology of mood disorders in children.

Answer 36

``` Based on small studies: 1. Depression: Preschoolers: 0.3% Elementary: 1-2% Adolescents: 5% Adults: 5-9% women, 2-3% men ``` ``` 2. Juvenile Bipolar Disorder: Prepubertal: ? About 0.5%; males possibly more Adolescent: Lifetime prevalence 1% Core syx but subsyndromal 5.7% No gender differences Adults: 0.4-1.6% (Bipolar I) ```

Question 37

What is the course of prepubertal major depression?

Answer 37

1. Typical depressive episode duration is 3-9 months. (up to 10% last 2 years). 2. Recurrence is 70% in 5 years. 3. 20-40% develop bipolar disorder within 5 years of depression. 4. Recurrent depressive episodes in adulthood.

Question 38

What are some adverse outcomes of major depression in children?

Answer 38

1. Impairment in school, family, friendships. 2. Increased risk of suicidal behaviors and suicide. 3. Tobacco and substance abuse. 4. Early parenthood.

Question 39

Describe the course of juvenile bipolar disorder.

Answer 39

1. High occurrence (59%) of psychosis. 2. 28.6 weeks to recovery 3. Low rates of recovery (37.1% at 1 year and 65.2% at 2 years; 4. For those who do recover, 55.2% relapse before second year of follow-up.

Question 40

For treatment of childhood depression what have shown to have equivalent efficacy to anti-depressants?

Answer 40

Psychosocial therapies: 1. CBT - Challenging distorted thoughts of negative view of self, others and future. - Behavioral activation. - Mood monitoring. - 64% remission rate in CBT vs. 39% for supportive therapy after 12-16 week treatment course. 2. IPT - interpersonal therapy - Focus on interpersonal conflicts, grief, role disputes, role transitions, interpersonal deficits. - 75% response rate IPT vs. 46% control group

Question 41

What meds work for treatment of childhood major depression?

Answer 41

1. SSRI's - watch for mania and suicide 2. atypical anti-depressants - such as Buproprion, Mirtazapine, Venlafaxine 3. DO NOT use tricyclics - they do not work in children and have risks of death

Question 42

What did the TADS study find about treatment of childhood depression?

Answer 42

Combination of anti-depressants and CBT is the best treatment.

Question 43

What is unique about the treatment of juvenile bipolar disorder?

Answer 43

Usually cannot treat without medications because the symptoms are so severe and disruptive.

Question 44

What is the treatment of juvenile bipolar disorder?

Answer 44

1. Depends on phase of illness. 2. Can try - Lithium, Valproate, Carbamazepine, Atypical Antipsychotics (side effect can be metabolic disorder with increased cholesterol and weight gain) 3. If psychotic, start with combination of mood stabilizer and antipsychotic 4. Can augment with education, mood hygiene, school interventions, support groups and CBT for anxiety and depression

Question 45

List the pediatric anxiety disorders.

Answer 45

1. Generalized Anxiety Disorder 2. Separation Anxiety Disorder 3. Selective Mutism 4. Specific Phobia 5. OCD 6. Social Phobia 7. Panic Disorder 8. (PTSD)

Question 46

What are the common clinical characteristics of pediatric anxiety disorders?

Answer 46

1. Developmentally inappropriate, unrealistic and excessive anxiety. 2. Subjective distress. 3. Cognitive– worry, catastrophizing 4. Physiological—heart, respirations and GI/GU 5. Anticipatory anxiety 6. Avoidance 7. Adult Accommodation - like conditioning of parents - they become overprotective because of the anxiety exhibited by their kids 8. Triggered by exposure 9. Wax and wane 10. Highly comorbid

Question 47

What are some things to look for in pediatric anxiety disorders?

Answer 47

1. Physical complaints: headaches, stomachaches, dramatic pain presentations. 2. Problems with falling asleep and middle of the night wakenings, repeated visits to parents’ room. 3. Eating problems—undereating when severe, overeating when milder. 4. Avoidance of outside and interpersonal activities: school, parties, camp, sleepovers, safe strangers. 5. Excessive need for reassurance: new situations, bedtime, school, storms, bad things happening 6. Inattention and poor performance at school. Not necessarily pervasive—some areas of preserved function.

Question 48

Do most pediatric anxiety disorders co-occur with another anxiety disorder?

Answer 48

Yes.

Question 49

What is something to be careful of when evaluating anxiety in a child?

Answer 49

There are some points in development when anxiety is normal - ie. separation anxiety in 18 month old.

Question 50

What are the criteria for separation anxiety disorder?

Answer 50

1. Inappropriate, excessive anxiety re: separation from home or attachment figures. 2. Need 3 or more: - Distress when separation from home or attachment figures occurs or is anticipated. - Worry about losing, or possible harm befalling attachment figures. - Worry that an untoward event will lead to separation from attachment figure. - Reluctance or refusal to go to school or elsewhere due to separation fear. - Fearful or reluctant to be alone at home or without significant adults in other settings. - Reluctance to got to sleep without being near an attachment figure or sleep away from home. - Repeated nightmares about separation. - Repeated physical complaints when separation occurs or is anticipated - Duration minimum 4 weeks.

Question 51

What are the criteria for generalized anxiety disorder and some characteristics?

Answer 51

1. Same DSM criteria as for adults, except for children you only need 1/6 symptoms. 2. 3-12% prevalence; girls = boys in childhood, but girls> boys in adolescence 3. Rarely presents alone. 4. Most common comorbidity = major depression.

Question 52

What is the prevalence of separation anxiety disorder?

Answer 52

1. 3.5-4.5% 2. girls get it more often than boys 3. genetics, modeling and parent-child relationship play a role 4. onset can be acute or insidious

Question 53

Symptoms of separation anxiety disorder can be produced by certain medications - which ones?

Answer 53

1. Haldol 2. Inderal 3. Pimozide

Question 54

When is separation anxiety normal?

Answer 54

Between at the ages of 18-30 months.

Question 55

Describe the criteria of selective mutism.

Answer 55

1. Consistent failure to speak in specific social situations despite speaking in other situations. 2. Disturbance interferes with educational achievement or social communication. 3. Duration at least 1 month 4. Failure to speak is not due to language problems. 5. Is not better accounted for by a Communication Disorder, and doesn’t occur only during a Pervasive Developmental Disorder or Psychotic Disorder.

Question 56

What are some characteristics of selective mutism?

Answer 56

1. Very rare, prevalence <1% 2. May be associated with excessive shyness, fear of social embarrassment, social isolation and withdrawal, clinging, temper tantrums or controlling and oppositional behavior. 3. They almost always get an additional diagnosis of another anxiety disorder (such as Social Phobia) within treatment settings.

Question 57

What are the criteria for a specific phobia?

Answer 57

1. Same DSM criteria as for adults except: - Children’s anxiety response may be expressed as crying, tantrums, freezing and clinging. - Children don’t have to realize that fear is excessive or unreasonable. - Duration at least 6 months. 2. 70% have another anxiety disorder.

Question 58

Describe OCD in children.

Answer 58

1. Same DSM criteria as for adults, except children don’t have to realize that the obsessions or compulsions are excessive and unreasonable. (And now in DSM-5, adults also don’t have to realize that this—specified with “poor” or “absent insight/delusional beliefs”) 2. Prevalence in kids 1-4% 3. In prepubertal population, common to see compulsions without obsessions. (obsessions are internal and compulsions are outward actions) 4. Children do exhibit transient age-appropriate OC behaviors that wax and wane with normal development, eg bedtime rituals, superstitions, concerns about sameness. It’s abnormal if it persists and causes excessive distress or impairment. 5. Be aware of PANDAS (Pediatric Autoimmune Neuropsychiatric Disorders Associated with Strep). Not a validated disorder at this time. Is post-strep onset of OCD.

Question 59

Describe the criteria for pediatric social anxiety/social phobia.

Answer 59

Same DSM criteria as for adults, except: 1. Child most show evidence of capacity for age-appropriate relationships with familiar people, and the symptoms must occur with peers as well as adults. 2. Children can express anxiety as crying, tantrums, freezing or shrinking. 3. Children don’t have to realize that it’s unreasonable. 4. Duration at least six months.

Question 60

What are some characteristics of social anxiety/social phobia?

Answer 60

1. 5-15% prevalence, more common in adolescence. 2. Average onset 11-12 years old. 3. Tends to be chronic and if untreated can persist into adulthood. 4. Comorbid with other anxiety disorders, ADHD, depression, and substance abuse.

Question 61

What are the criteria for panic disorder in children?

Answer 61

Same exact DSM criteria as for adults. 1. Rare in children, common in adolescents. 2. Prepubertal onset may signal greater severity. 3. Attacks often begin at onset of or during episodes of depression or separation anxiety.

Question 62

What is the general treatment for pediatric anxiety disorders?

Answer 62

1. SSRI's are the first line treatment for generalized anxiety disorder, separation anxiety disorder, social phobia and panic disorder. 2. psychosocial therapies include: A number of psychosocial treatments exist for treating anxiety disorders, but CBT is the only one supported by randomized, controlled studies. “The Coping Cat” (Kendall, 1990). Recognizing anxious feelings and thoughts, identifying somatic reactions and developing a plan to cope.

Question 63

How is OCD treated?

Answer 63

1. Complicated to treat. 2. Clomipramine and SSRI’s 3. Exposure with Response Prevention (ERP) 4. Combined treatment probably best.

Question 64

How is specific phobia treated?

Answer 64

1. Graduated, in-vivo exposure with contingency management. | 2. Medication not effective unless comorbidity.

Question 65

How is panic disorder treated?

Answer 65

Not studied much in kids—use adult treatments.

Question 66

How is social phobia treated?

Answer 66

CBT: psychoeducation, exposure, skill building, homework.

Question 67

How is selective mutism treated?

Answer 67

Not much data? Prozac

Question 68

Describe the diagnostic criteria for early onset schizophrenia.

Answer 68

1. Same diagnostic criteria as for adults. 2. Very rare disorder: < age 15, 14/100000; prepubertal even more rare, 1.6/100000. Consider a wide range of differential diagnosis. 3. Difficult to diagnose psychosis in children due to: - Overactive imaginations - Developmental delays - Language problems - Postraumatic phenomena - Misperceptions of questions asked.

Question 69

A child with new onset psychosis requires what>

Answer 69

A full medical work-up, including investigation of endocrinologic, metabolic, neurologic, infectious and toxic causes.

Question 70

How is early onset schizophrenia treated?

Answer 70

``` 1. Medications: First line: atypical antipsychotics Second line: Typical antipsychotics Considered for treatment-resistant cases Clozapine ECT 2. Psychosocial interventions Psychoeducation Behaviorally-based family therapy (Goldstein and Miklowitz) Cognitive-behavioral therapy (Rector and Beck) Weight management SPED/vocational training ```

Question 71

Are sleep problems in kids and adolescents common?

Answer 71

Yes, about 20-30% have them. They require careful assessment.

Question 72

What are the assessment tools when evaluating sleep problems in kids?

Answer 72

Sleep diaries ( to assess sleep schedules and amounts); ask about bedtime routines and sleep associations, unusual behaviors in sleep, sleep-related breathing problems, daytime alertness; conduct a physical exam looking for Obstructive Sleep Apnea risk factors (craniofacial anomalies, tonsiller size, septal deviation of nose.)

Question 73

What medical conditions are part of the differential diagnosis for pediatric sleep disorders?

Answer 73

``` Allergies/eczema Asthma GERD Migraine headaches Neuromuscular Disorders Arnold-Chiari Malformation Chronic Renal Failure Seizure Disorders Ear Infections Diabetes Mellitus Pain Syndromes Iron deficiency anemia Hyperthyroidism Hypothyroidism Substances/Medications ```

Question 74

What psychiatric disorders are part of the differential diagnosis for pediatric sleep disorders?

Answer 74

``` Anxiety Disorders Mood Disorders Disruptive Behavior Disorders Posttraumatic Stress Disorder Pervasive Developmental Disorder Psychotic Disorders Substance use disorders Reactive Attachment Disorder Obsessive Compulsive Disorder ```

Question 75

What psychosocial disorders are part of the differential diagnosis for pediatric sleep disorders?

Answer 75

``` Abuse Chaotic Home Life TV/computer in bedroom Parental sleep disorder Inappropriate sleep-onset associations Marital conflict New infant in home ```

Question 76

Describe sleep onset association disorder.

Answer 76

1. Affects 25-50% of 6-12 month olds; 15-20% of 1-3 year olds. 2. Signs/symptoms: - Calls for parents after night wakings - Sleep initiation requires parental involvement - Inappropriate sleep associations (falls asleep in parents’ arms). 3. Treatment: Behavioral interventions, Put to bed awake but sleepy, New routines

Question 77

What are Parasomnias?

Answer 77

Disorders of arousal that are now grouped as NREM sleep arousal disorders. The child will look like they are awake, but the EEG shows that they are asleep.

Question 78

List the parasomnia disorders.

Answer 78

1. Sleep terrors | 2. Sleep walking

Question 79

Describe sleep terrors.

Answer 79

1. Toddlers and school-age children 2. 3% prevalence 3. Occurs during first third of the night; autonomic arousal with tachycardia, tachypnea, sweating, inconsolable screaming; amnesia for the event. 4. Treatment = Reassurance of parents; avoid sleep deprivation; benzodiazepines for severe cases.

Question 80

Describe sleep walking.

Answer 80

1. 4 to 8 year olds 2. 15-40% have one episode; 3-4% weekly/monthly episodes. 3. Occur 1-2 hours after sleep onset; walk for a few mins. up to ½ hour; confusion; incoherence; difficult to awaken; amnesia for the event. 4. Treatment= Reassurance, safety measures; benzo’s in severe cases.

Question 81

Describe the characteristics of obstructive sleep apnea in children.

Answer 81

1. Occurs in 1-2% of children 2. Habitual snoring; noisy breathing; pauses in breathing; nocturnal sweating; mouth breathing. 3. Diagnosed by sleep study. 4. Treatment is Adenotonsillectomy (if appropriate) and CPAP.

Question 82

Describe delayed sleep phase syndrome in adolescents.

Answer 82

1. Most common in adolescents due to the normal delay in circadian rhythms. 2. Delay in sleep onset by 3-4 hours, then difficulty waking up in the a.m. causing sleep deprivation, impaired academic functioning, conflict with parents. 3. Disorder is defined by society, as sleep quality and quantity normal if patient sleeps on his/her own schedule. 4. Treatment = light therapy, behavioral interventions, possibly Melatonin.

Question 83

Describe narcolepsy in children.

Answer 83

1. Starts in adolescence 2. 0.05% prevalence 3. Cataplexy, hypnogogic hallucinations, sleep paralysis, sleep attacks. 4. Diagnosed by Polysomnogram and Multiple Sleep Latency Test, hypocretin deficiency in CSF 5. Treatment = Modafinil or stimulants for daytime sleepiness; SSRI’s or TCA’s for cataplexy; scheduled naps.

Question 84

What are the guidelines for good sleep hygiene for children?

Answer 84

1. Schedule bedtime and wake-up 2. Synchronize the sleep-wake rhythm with the circadian clock using light in am at scheduled wake time. 3. Exercise during the day 4. Hot bath few hours before bed. 5. Avoid daytime naps, excessive temperature, noise, light, alcohol and caffeine 6. Time in bed: only for sleep.

Question 85

What are two elimination disorders.

Answer 85

1. encopresis | 2. enuresis

Question 86

Describe the criteria for Encopresis.

Answer 86

1. Repeated passage of feces into inappropriate places whether involuntary or intentional 2. At least one event per month for at least three months. 3. Chronological (or equivalent developmental level) is at least four years. 4. Not due exclusively to a substance or general medical condition except through a mechanism involving constipation. - With constipation and overflow incontinence - Without constipation and overflow incontinence.

Question 87

What are some characteristics of Encopresis?

Answer 87

1. Occurs in 1% of 5 year olds. 2. Distinguish from organic causes (Hirshsprung’s Disease, Crohn’s disease, Irritable Bowel Syndrome, use of laxatives.) 3. Causes: Precipitating psychosocial stressors Expression of anger, ODD Initiation of a cycle of chronic constipation (anal fissure, struggle over toilet training, phobic avoidance of toilet), leading to fecal retention, weakening of anal sphincter and decreased sensation in the rectum. Psychodynamic explanations: the mother-child relationship and maternal ambivalence regarding child’s autonomy. 4. Treatment: Medical management of constipation. 10 minute toilet sittings 20 minutes after meals. Behavioral incentive programs. Aversive consequences for soiling accidents. Psychotherapy/family therapy if needed.

Question 88

What are the criteria for enuresis?

Answer 88

1. Repeated voiding of urine into bed or clothes (whether involuntary or intentional). 2. Either 2x/week for 3 consecutive months, or clinical distress or impairment. 3. Chronological (or developmental ) age at least five years. 4. Not due to substance or medical condition. 5. can be Nocturnal only, Diurnal only, or Nocturnal and Diurnal

Question 89

Describe some characteristics of enuresis.

Answer 89

1. Nocturnal enuresis in 15% of five-year-olds, with a decrease of about 15% per year afterwards. 2. Rule out diabetes mellitus, diabetes insipidus, psychogenic polydipsia, UTI, seizure disorders, renal insufficiency, neurogenic bladder conditions, neuroleptic-induced enuresis, urinary tract anomalies. 3. Etiology: Maturational delay Genetic disorder Manifestation of stress 4. Treatment: Usually a self-limited, benign disorder 5. Pre-treatment period: charting of symptoms, positive reinforcement of dry periods, nighttime fluid restriction and encouragement of nighttime urination. 6. Enuresis alarm (bell and pad) DDAVP, Imipramine

Question 90

What is the most lethal eating disorder?

Answer 90

Anorexia nervosa. Prevalence is low but society is increasingly fixated on being thin and losing weight.

Question 91

What are some covert signs of anorexia nervosa/eating disorders?

Answer 91

1. high risk groups - (runner, skaters, gymnasts, models, dancers, wrestlers, cystic fibrosis, diabetes, depression, sexual abuse) 2. watch for bulky, oversized clothing 3. physical signs - obsession with food/cooking; frequent trips to the bathroom; food preferences.