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1. Child and Adolescent Psychiatry > Child Specific Notes: Deck 2 (suicide, anxiety, OCD, trauma, feed/eat, elimination) > Flashcards

Child Specific Notes: Deck 2 (suicide, anxiety, OCD, trauma, feed/eat, elimination) Flashcards

1
Q

when is the peak of hospitalizations due to suicide

A

between 15-19 years old

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2
Q

how does the rate of suicide attempts compare to the rate of completions

A

SA rates 15x higher than completions

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3
Q

what is the most common method of completing suicide in canada

A

hanging

(firearms in USA)

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4
Q

when does rate of SI increase in C&A

A

increases significantly after puberty

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5
Q

what % of kids 10-14 have experienced SI?

A

7-10 %

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6
Q

what % of kids 10-14 have shown suicidal behaviour (and seek care)

A

0.0015%

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7
Q

what % of kids 10-14 die by suicide

A

0.001%

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8
Q

what % of adolescents 15-19 have
1. experienced SI
2. has suicidal behaviour
3. die by suicide

A
  1. 14-20%
  2. 3-10%
  3. 0.013% M, 0.002% F
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9
Q

what is the most significant risk factor for suicide

A

having a psychiatric disorder

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10
Q

risk factors for suicide in youth

A

older
male
indigenous or caucasian
psychiatric d/o
multiple psych d/os
family history of suicide
previous suicide attempt

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11
Q

what intervention is most likely to decrease suicides per APA

A

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

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12
Q

what are the 3 most efficient categories of intervention for SI per APA

A
  1. limitation of access to lethal means
  2. preservation of contact with patients hospitalized for SA after hospitalizaiton
  3. implementation of emergency call centers
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13
Q

name 2 tools that have positive predictive value in identifying those at risk for suicide and suicidal behaviour in the near and long term

A

PHQ9 and CSSRS

*this is across diagnosis

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14
Q

what is the goal of suicide risk assessment

A

not to predict suicide but to appreciate the basis for suicidality and thus to allow for a more informed intervention

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15
Q

list warning signs for suicide

A

psychosis

suicidal communication or prep behaviours

marked change in functioning

service utilization

new and intense family concerns

evasive history

rapid changes in reported SI

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16
Q

what intervention has the most evidence for “preventing” suicide in adolescents with a history of self harm

A

group therapy (level 1a)

also CBT, DBT for BPD
family inclusive interventions

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17
Q

list 5 public health interventions aimed at preventing suicide

A
  1. means restriction
    –> bridge and subway barriers, firearms restriction, tylenol packaging restrictions, restrictions on sale of OTC drugs, pesticide regulations
  2. school based programs
    –> for teens, kids, staff; there have been significant results from school based awareness programs in decreasing SI and SA
  3. public awareness campaigns
    –> for gen pop, adult M, gay M
  4. gatekeeper training
    –> for school staff, crisis counsellors, veterans, indigenous people, gen pop
  5. media reporting guidelines
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18
Q

list medication/medical interventions that prevent suicide

A

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

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19
Q

is there evidence that safety planning is effective

A

yes

RCT showed 50% decrease in suicidal behaviour after ED visit with increased follow up

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20
Q

what are the most common anxiety disorders in kids and teens (ranked from most to least common)

A

specific phobia (BII, animal)

SAD

PTSD

panic

separation

GAD

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21
Q

what is the earliest onset of anxiety disorders in kids? median onset?

A

earliest 6 years

median 11 years

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22
Q

where does fear originate

A

amygdala

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23
Q

where does worry originate

A

cortico-striatal-thalamic-cortical loop

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24
Q

what are the most common comorbidities with separation anxiety in C&A

A

GAD, specific phobia

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25
Q

how does the dx of separation anxiety differ between kids and adults

A

in kids must have sx for 4 weeks

in adults must have sx for 6 months

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26
Q

how do you treat separation anxiety

A

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

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27
Q

in separation anxiety with school refusal, in addition to fluoxetine or fluvoxamine, what other meds might you consider

A

citalopram

adjunctive imipramine

do NOT recommend alprazolam

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28
Q

list 3 anxiety rating scales for kids

A

MASC-2 (multidimentional anxiety scale for children)

CSAS (childrens separation anxiety scale)

SCARED (screen for child anxiety related emotional disorders)

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29
Q

how do you treat selective mutism

A

CBT type approach with systematic desensitization, social skills training, systematic reinforcement of speech behaviour

possibly fluoxetine but limited evidence

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30
Q

name a screening tool for selective mutism

A

selective mutism questionnaire

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31
Q

name a screening tool for specific phobias

A

specific phobia questionnaire

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32
Q

when is the mean age of onset for SAD

A

12

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33
Q

name a rating sale for social anxiety

A

liebowitz social anxiety rating scale

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34
Q

name two rating scales for panic disorder

A

panic and agoraphobia scale

panic disorder severity scale

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35
Q

desribe the bimodal onset of GAD

A

one peak at 10-14 years and one peak at 31-32 years

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36
Q

how does diagnosis of GAD differ between C&A and adults

A

in adults, you need excessive worry AND 3+ of other sx

in kids/teens, only need excessive worry plus ONE other additional symptom

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37
Q

name 3 co-occurring conditions with anxiety that require an adapted CBT protocol

A

comorbid ADHD, aggression, SUD require adapted protocols

38
Q

how do you treat GAD in C&A population

A

*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

39
Q

other than CBT, list other nonpharm treatments for GAD in C&A

A

attention bias modification

MBCT

social effectiveness training (SAD)

ERP

family based CBT

metacognitive tx (OCD)

etc

40
Q

is there a trial of a med specifically in separation anxiety

A

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)

41
Q

list 5 rating scales for GAD

A

GAD-7

HAM-A

Beck Anxiety Inventory

Penn State Worry Questionnaire

SCAREDD

42
Q

what impact does family accommodation have on treatment for OCD

A

decreases response to treatment

43
Q

what obsessions indicate the person will have a poorer response to SSRIs

A

hoarding and symmetry

44
Q

list factors that suggest a poor prognosis in OCD

A

early age of onset

yielding to compulsions

hospitalization

bizarre compulsions

less insight

comorbidities

45
Q

what % of people w OCD have sx that remit without treatment

A

20-40%

46
Q

what % of those with OCD have a suicide attempt

A

25%

47
Q

how do you treat OCD in C&A

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)

48
Q

what med can be added to ERP that might make it more effective to treat OCD

A

d-cycloserine

49
Q

name a trial that looked at treatment of OCD in C&A

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

50
Q

what are neuroanatomical changes in OCD

A

smaller caudate, but caudate shows more activity

hyperactivity in anterior cingulate

inhibitory CSTC pathway is implicated

51
Q

list cognitive schemas present in OCD

A

thought action fusion

increased sense of vulnerability

enhanced responsibility for own and others wellbeing

52
Q

name the rating scale used for C&A OCD

A

CY-BOCS

53
Q

what is defined as response to an intervention in OCD

A

decrease of 25% or more on the CY-BOCS

54
Q

how do you treat PANDAS (including neuropsych symptoms)

A

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 )

55
Q

is there any pharmacological treatment for the core symptoms of reactive attachment disorder or disinhibited social engagement disorder

A

no

56
Q

neglect has to be before what age to predispose to DSED

A

before age 2

no evidence that neglect after this is associated with DSED

57
Q

what is the treatment approach to RAD

A

aim of treatment is to provide the child with an emotionally available attachment figure

  1. 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.
  2. Psych assessment to r/o comorbid disorders.
  3. Assess safety of current placement as high risk for being re-traumatized.
  4. Aim of Rx is to provide child w/emotionally available attachment figure.
  5. For DSED, limit contacts w/non-caregiving adults to reduce signs of d/o.
  6. Adjunctive interventions if aggressive or oppositional behaviour present.
  7. No pharmacological Rx for core features of RAD or DSED.
  8. 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.
58
Q

PTSD can occur at any age after…

A

after 1 year old

59
Q

are there any preventative strategies for PTSD

A

no

debriefing is NOT recommended

*screen and treat is preferred

60
Q

what is a protective factor in development of PTSD

A

social support is PROTECTIVE against PTSD except in the event of poor attachment hx

61
Q

list factors that suggest good prognosis in PTSD

A

rapid onset of sx

short duration of less than 6 mo

better premorbid functioning

strong social connections

no comorbidities

62
Q

how does PTSD diagnosis differ in kids under 6 compared to everyone else

A

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.

63
Q

what % of those with acute stress disorder develop PTSD

A

50%

64
Q

what intervention in acute stress disorder has some evidence for preventing transition to PTSD

A

CBT/TF-CBT

dont do it before 2-3 weeks after trauma

65
Q

what meds might have some protective effects post trauma

A

propanolol and morphine

but cochrane review says not enough evidence propanolol prevents PTSD

66
Q

what % of children experience a MH disorder

A

20%

67
Q

what are the most common MH disorders in kids

A

anxiety

68
Q

what are the two leading causes of death among Canadian youth

A

accidents = #1
suicide = #2

25% of all deaths aged 15-24 are suicide

69
Q

how does the risk of dying by suicide change for indigenous youth

A

indigenous youth die by suicide 5-6x more than non indigenous youth

70
Q

how many kids in canada actually receive appropriate MH service

A

1/5

71
Q

who has a better prognosis in functional neurological disorder, kids or adults

A

kids

kids also have better. prognosis than adolescent

72
Q

when is the avergae age of onset for anorexia nervosa

A

ages 14-18 years

rare before puberty
rare after 40

73
Q

list indications for admission for C&A with AN

A

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

74
Q

should meds be used as the primary treatment for AN

A

no–> risk of orthostasis and bradycardai

75
Q

below what body weight are SSRIs ineffective

A

below 80% IBW

76
Q

what symptoms in AN might improve just with weight gain

A

OCD and depression sx

77
Q

what are the first goals of treatment for AN in C&A

A

NUTRITIONAL REHAB
psychoeducation
support

antidepressants and psychotherapy do not work in the context of malnutrition

78
Q

what is the first line psychotherapeutic treatment for AN in C&A

A

Maudsley Family Therapy

79
Q

who is the idea candidate for Maudsley family therapy for AN

A

aged under 18

ED less than 3 years duration

dx of AN

80
Q

what is phase 1 of maudsley family therapy

A

weight restoration –> parents take on responsibility to refeed youth

externalization of illness

aim to return to healthy weight within 3 mo

81
Q

what is phase 2 of maudsley family therapy

A

returning control of eating to the adolescent

82
Q

what is phase 3 of maudsley family therapy

A

establishing healthy adolescent identity (initiated once above 95% IBW)

83
Q

how much weight are you hoping a kid with AN will gain per week as an inpatient? outpatient?

A

inpatient: 2-3 pounds/wk

outpatient: 0.5-1 pound/week

84
Q

after first line maudsley family therapy, what are the second line therapies for AN in C&A

A

Family based treatment
–> adolescent focused therapy if FBT not available

CBT
IPT
MET

85
Q

third line for treatment of AN in C&A

A

SSRIs or AAPs for comorbid disorders

benzoes before meal can decrease anxiety

86
Q

name two rating scales for AN

A

Eating Attitudes Test (EAT-26)

Eating Disorder Diagnostic Scale (EDDS) –> ages 13-65, screens for AN, BN, BED

87
Q

list the psychotherapies found to be effective in binge eating disorder

A

CBT
IPT
DBT

should be offered to adolescents

88
Q

list meds for binge eating disorder

A

sertraline
citalopram
fluoxetine

imipramine

topiramate

vyvanse–> for mod-severe BED but be careful cuz can worsen BN

89
Q

how do you treat BN in C&A

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

90
Q

indications for admission in BN

A

syncope

K below 3mmol/L

esophageal tears

cardiac arrhythmias

suicide risk

intractable vomiting

hematemesis

failure to respond to outpatient treatment

hypothermia

91
Q
A

1. Child and Adolescent Psychiatry (32 decks)

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