Child Specific Notes: Deck 2 (suicide, anxiety, OCD, trauma, feed/eat, elimination) Flashcards
when is the peak of hospitalizations due to suicide
between 15-19 years old
how does the rate of suicide attempts compare to the rate of completions
SA rates 15x higher than completions
what is the most common method of completing suicide in canada
hanging
(firearms in USA)
when does rate of SI increase in C&A
increases significantly after puberty
what % of kids 10-14 have experienced SI?
7-10 %
what % of kids 10-14 have shown suicidal behaviour (and seek care)
0.0015%
what % of kids 10-14 die by suicide
0.001%
what % of adolescents 15-19 have
1. experienced SI
2. has suicidal behaviour
3. die by suicide
- 14-20%
- 3-10%
- 0.013% M, 0.002% F
what is the most significant risk factor for suicide
having a psychiatric disorder
risk factors for suicide in youth
older
male
indigenous or caucasian
psychiatric d/o
multiple psych d/os
family history of suicide
previous suicide attempt
what intervention is most likely to decrease suicides per APA
24 hour crisis teams
theory is that SI is a coupled and brief experience–> if you can intervene briefly and immediately, then you can disrupt the coupling of SI with plan and means which is usually somewhat transient
what are the 3 most efficient categories of intervention for SI per APA
- limitation of access to lethal means
- preservation of contact with patients hospitalized for SA after hospitalizaiton
- implementation of emergency call centers
name 2 tools that have positive predictive value in identifying those at risk for suicide and suicidal behaviour in the near and long term
PHQ9 and CSSRS
*this is across diagnosis
what is the goal of suicide risk assessment
not to predict suicide but to appreciate the basis for suicidality and thus to allow for a more informed intervention
list warning signs for suicide
psychosis
suicidal communication or prep behaviours
marked change in functioning
service utilization
new and intense family concerns
evasive history
rapid changes in reported SI
what intervention has the most evidence for “preventing” suicide in adolescents with a history of self harm
group therapy (level 1a)
also CBT, DBT for BPD
family inclusive interventions
list 5 public health interventions aimed at preventing suicide
- means restriction
–> bridge and subway barriers, firearms restriction, tylenol packaging restrictions, restrictions on sale of OTC drugs, pesticide regulations - school based programs
–> for teens, kids, staff; there have been significant results from school based awareness programs in decreasing SI and SA - public awareness campaigns
–> for gen pop, adult M, gay M - gatekeeper training
–> for school staff, crisis counsellors, veterans, indigenous people, gen pop - media reporting guidelines
list medication/medical interventions that prevent suicide
lithium
–> in unipolar and bipolar patients
clozapine
–> in patients with SCZ
antidepressants
–> for patients with MDD taking SSRIs–> less robust evidence than for lithium and clozapine
ketamine
–> promising initial evidence
ECT
–> for patients with MDD
is there evidence that safety planning is effective
yes
RCT showed 50% decrease in suicidal behaviour after ED visit with increased follow up
what are the most common anxiety disorders in kids and teens (ranked from most to least common)
specific phobia (BII, animal)
SAD
PTSD
panic
separation
GAD
what is the earliest onset of anxiety disorders in kids? median onset?
earliest 6 years
median 11 years
where does fear originate
amygdala
where does worry originate
cortico-striatal-thalamic-cortical loop
what are the most common comorbidities with separation anxiety in C&A
GAD, specific phobia
how does the dx of separation anxiety differ between kids and adults
in kids must have sx for 4 weeks
in adults must have sx for 6 months
how do you treat separation anxiety
most evidence is for CBT/exposure treatment with family involvement and early intervention
can also consider:
fluoxetine
fluvoxamine
(?sertraline?)
if meds are indicated
do NOT recommend clonazepam
in separation anxiety with school refusal, in addition to fluoxetine or fluvoxamine, what other meds might you consider
citalopram
adjunctive imipramine
do NOT recommend alprazolam
list 3 anxiety rating scales for kids
MASC-2 (multidimentional anxiety scale for children)
CSAS (childrens separation anxiety scale)
SCARED (screen for child anxiety related emotional disorders)
how do you treat selective mutism
CBT type approach with systematic desensitization, social skills training, systematic reinforcement of speech behaviour
possibly fluoxetine but limited evidence
name a screening tool for selective mutism
selective mutism questionnaire
name a screening tool for specific phobias
specific phobia questionnaire
when is the mean age of onset for SAD
12
name a rating sale for social anxiety
liebowitz social anxiety rating scale
name two rating scales for panic disorder
panic and agoraphobia scale
panic disorder severity scale
desribe the bimodal onset of GAD
one peak at 10-14 years and one peak at 31-32 years
how does diagnosis of GAD differ between C&A and adults
in adults, you need excessive worry AND 3+ of other sx
in kids/teens, only need excessive worry plus ONE other additional symptom
name 3 co-occurring conditions with anxiety that require an adapted CBT protocol
comorbid ADHD, aggression, SUD require adapted protocols
how do you treat GAD in C&A population
*psychological treatments are preferred
*combo is better than either therapy or meds alone
meds:
fluoxetine
fluvoxamine
sertraline
do NOT recommend alprazolam for GAD alone
*if school refusal, consider citalopram, adding imipramine to CBT or alprazolam
other than CBT, list other nonpharm treatments for GAD in C&A
attention bias modification
MBCT
social effectiveness training (SAD)
ERP
family based CBT
metacognitive tx (OCD)
etc
is there a trial of a med specifically in separation anxiety
yes, the CAMS trial
looked at sertraline vs CBT in separation anxiety
combo was better than either alone (either alone were equal to each other)
list 5 rating scales for GAD
GAD-7
HAM-A
Beck Anxiety Inventory
Penn State Worry Questionnaire
SCAREDD
what impact does family accommodation have on treatment for OCD
decreases response to treatment
what obsessions indicate the person will have a poorer response to SSRIs
hoarding and symmetry
list factors that suggest a poor prognosis in OCD
early age of onset
yielding to compulsions
hospitalization
bizarre compulsions
less insight
comorbidities
what % of people w OCD have sx that remit without treatment
20-40%
what % of those with OCD have a suicide attempt
25%
how do you treat OCD in C&A
psychotherapeutic approaches are preferred –> CBT ERP (or combo)
for meds:
level 1
fluoxetine
clomipramine
level 2
citalopram
fluvoxamine
paroxetine
sertraline
can consider adjunctive aripiprazole
consider adjunctive riluzole (glutamate antagonist)
what med can be added to ERP that might make it more effective to treat OCD
d-cycloserine
name a trial that looked at treatment of OCD in C&A
POTS study
showed the combo was better than CBT alone which was better than meds alone
all were better than placebo
med was sertraline
what are neuroanatomical changes in OCD
smaller caudate, but caudate shows more activity
hyperactivity in anterior cingulate
inhibitory CSTC pathway is implicated
list cognitive schemas present in OCD
thought action fusion
increased sense of vulnerability
enhanced responsibility for own and others wellbeing
name the rating scale used for C&A OCD
CY-BOCS
what is defined as response to an intervention in OCD
decrease of 25% or more on the CY-BOCS
how do you treat PANDAS (including neuropsych symptoms)
i’m not gonna learn all this….
but basically NSAIDS and corticosteroids
consider high dose IVIG or other corticosteroid sparing agent
CBT and supportive therapy
consider strep prophylaxis (some controversy )
is there any pharmacological treatment for the core symptoms of reactive attachment disorder or disinhibited social engagement disorder
no
neglect has to be before what age to predispose to DSED
before age 2
no evidence that neglect after this is associated with DSED
what is the treatment approach to RAD
aim of treatment is to provide the child with an emotionally available attachment figure
- If Hx foster care/adoption/institutional rearing, routinely ask about attachment & reticence w/ strangers. 2. Obtain direct evidence from Hx child’s patterns of attachment w/primary caregivers and observe
interactions w/caregivers. Can use a structured observational paradigm to compare behaviours
w/familiar and unfamiliar adults. - Psych assessment to r/o comorbid disorders.
- Assess safety of current placement as high risk for being re-traumatized.
- Aim of Rx is to provide child w/emotionally available attachment figure.
- For DSED, limit contacts w/non-caregiving adults to reduce signs of d/o.
- Adjunctive interventions if aggressive or oppositional behaviour present.
- No pharmacological Rx for core features of RAD or DSED.
- No physical restraints or coercion of trauma, or promotion of regression for “reattachment” as not
evidence based and asso’d w/serious harm, including death.
PTSD can occur at any age after…
after 1 year old
are there any preventative strategies for PTSD
no
debriefing is NOT recommended
*screen and treat is preferred
what is a protective factor in development of PTSD
social support is PROTECTIVE against PTSD except in the event of poor attachment hx
list factors that suggest good prognosis in PTSD
rapid onset of sx
short duration of less than 6 mo
better premorbid functioning
strong social connections
no comorbidities
how does PTSD diagnosis differ in kids under 6 compared to everyone else
If <6yo, can occur to parent/caregiver, either ≥1 in intrusion, ≥1 in avoidance or -ve alterations in cognition, and ≥2
alteration in arousal/reactivity, can be seen through nightmares/frightening dreams w/o recognizable content,
repetitive play, re-enactment, socially withdrawn behaviours, developmental regression.
what % of those with acute stress disorder develop PTSD
50%
what intervention in acute stress disorder has some evidence for preventing transition to PTSD
CBT/TF-CBT
dont do it before 2-3 weeks after trauma
what meds might have some protective effects post trauma
propanolol and morphine
but cochrane review says not enough evidence propanolol prevents PTSD
what % of children experience a MH disorder
20%
what are the most common MH disorders in kids
anxiety
what are the two leading causes of death among Canadian youth
accidents = #1
suicide = #2
25% of all deaths aged 15-24 are suicide
how does the risk of dying by suicide change for indigenous youth
indigenous youth die by suicide 5-6x more than non indigenous youth
how many kids in canada actually receive appropriate MH service
1/5
who has a better prognosis in functional neurological disorder, kids or adults
kids
kids also have better. prognosis than adolescent
when is the avergae age of onset for anorexia nervosa
ages 14-18 years
rare before puberty
rare after 40
list indications for admission for C&A with AN
weight <75% IBW
HR <50bpm daytime, <45bpm overnight
sBP < 90mmHg
orthostasis (HR above 20bpm, BP >10mmHg)
arrhythmia
temp below 35.5 celsius
hypoK, hypoMg, hypoPhos
body fat less than 10%
acute food refusal
failed response to outpatient treatment
should meds be used as the primary treatment for AN
no–> risk of orthostasis and bradycardai
below what body weight are SSRIs ineffective
below 80% IBW
what symptoms in AN might improve just with weight gain
OCD and depression sx
what are the first goals of treatment for AN in C&A
NUTRITIONAL REHAB
psychoeducation
support
antidepressants and psychotherapy do not work in the context of malnutrition
what is the first line psychotherapeutic treatment for AN in C&A
Maudsley Family Therapy
who is the idea candidate for Maudsley family therapy for AN
aged under 18
ED less than 3 years duration
dx of AN
what is phase 1 of maudsley family therapy
weight restoration –> parents take on responsibility to refeed youth
externalization of illness
aim to return to healthy weight within 3 mo
what is phase 2 of maudsley family therapy
returning control of eating to the adolescent
what is phase 3 of maudsley family therapy
establishing healthy adolescent identity (initiated once above 95% IBW)
how much weight are you hoping a kid with AN will gain per week as an inpatient? outpatient?
inpatient: 2-3 pounds/wk
outpatient: 0.5-1 pound/week
after first line maudsley family therapy, what are the second line therapies for AN in C&A
Family based treatment
–> adolescent focused therapy if FBT not available
CBT
IPT
MET
third line for treatment of AN in C&A
SSRIs or AAPs for comorbid disorders
benzoes before meal can decrease anxiety
name two rating scales for AN
Eating Attitudes Test (EAT-26)
Eating Disorder Diagnostic Scale (EDDS) –> ages 13-65, screens for AN, BN, BED
list the psychotherapies found to be effective in binge eating disorder
CBT
IPT
DBT
should be offered to adolescents
list meds for binge eating disorder
sertraline
citalopram
fluoxetine
imipramine
topiramate
vyvanse–> for mod-severe BED but be careful cuz can worsen BN
how do you treat BN in C&A
1st line = Family based treatment (FBT) > CBT for adolescent > IPT as alternative
there is growing evidence for DBT
2nd line = SSRIs, may be useful for comorbid d/o –> FLUOXETINE has best evidence
indications for admission in BN
syncope
K below 3mmol/L
esophageal tears
cardiac arrhythmias
suicide risk
intractable vomiting
hematemesis
failure to respond to outpatient treatment
hypothermia
