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BSM Board Exam > Clinical Management, pediatric > Flashcards

Clinical Management, pediatric Flashcards

1
Q

What are considered healthy sleep habits in children?

A

Practice promoting sleep regulation (circadian and sleep drive
Practices that promote sleep conditions
Reduce arousal and promote relaxation
Practices that promote adequate sleep quantity and quality

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2
Q

What are practices that promote sleep regulation in pediatrics?

A

Maintain consistent sleep-wake cycle
Set and enforce consistent bedtime weekdays and weekends
Set and enforce a consistent wake time weekdays and weekends
Keep regular daily schedules of activities, including meals
Avoid bright light in bedroom at his and during night
Increase light exposure in morning
Establish appropriate napping schedule

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3
Q

What are practices that promote sleep conditions in pediatrics?

A

Establish regular and consistent bedtime routine
Limit activities that promote wakefulness
Don’t use bed for punishment
Avoid sleeping in environments other than bedroom

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4
Q

What practices reduce arousal and promote relaxation for children?

A 
Electronics out of the bedroom
Reduce stimulating play at bedtime
Avoid heavy meals 1-2 hrs before bed
Reduce cognitive and emotional stimulation before bedtime
Limit or eliminate caffeine consumption
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5
Q

What are practices that promote adequate sleep quantity and quality for children?

A

Set an age-appropriate bedtime and wake time to ensure adequate sleep
Maintain a safe and comfortable sleeping environment

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6
Q

What is the definition of Extinction?

What is it used for?

A

Behavioral medicine principles:
Behavioral theory’s principle of elimination a previously reinforced behavioral response

Extinction is effective in reducing inappropriate bedtime behaviors
e.g. crying, tantrums, repeatedly getting OOB

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7
Q

What results in maintenance of inappropriate bedtime behaviors

A

Behaviors are often maintained by reinforcement of parent attention and insufficient limit setting

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8
Q

What are the procedures of approach with Extinction?

A 
Time out from positive reinforcement (e.g. parent attention)
Planned ignoring (of attention maintained disruptive behaviors)
Extinction of escape and avoidance behaviors
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9
Q

What are the steps involved in the Extinction approach?

A

Assessment
Information
Bedtime routine
Reinforcement for appropriate behaviors and unmodified extinction

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10
Q

How is Standard/unmodified extinction carried out?

A

Extinguishing infant crying at bedtime by discontinuing the reinforcement of child crying via parental attention/presence

Parents have been reinforcing the child’s crying at bedtime (e.g. staying or returning to comfort the child when crying.)

Std extinction = putting the infant to bed while drowsy w/adequate need for sleep, remotely monitor for safety. Do not return to comfort child.

Requires parent to tolerate child crying. Need strong support system.

During first 3-5 nights of intervention, therapist and parent have daily phone/email contact. Therapist provides parents support.

Extinction doesn’t lead to worsening of parent-child relationship

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11
Q

What is an extinction burst?

A

Frequency and severity of inappropriate bedtimes behavior may increase during the first night of treatment

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12
Q

What is spontaneous recovery?

A

Reoccurrence of problems that usually occurs with a change in environment

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13
Q

What is the data to support standard extinction?

A

Large treatment effect size
Effectiveness in children w/ dev. Disabilities
+ effects on parental well-being and child’s daytime behavior

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14
Q

What are indications for Graduated Extinction w/ and w/o parent

A

For bedtime problems and night time wakening’s involving inappropriate sleep associations and/or limit- setting problems, in young children (ages 6 mos to 5 years)
Indicated for insomnia

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15
Q

What is sleep onset insomnia in children?

A

Typically seen in children >= 6 months

Caused by neg. Sleep onset associations that interfere w/ falling asleep and going back to sleep independently at night

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16
Q

What is limit-setting insomnia in children?

A

Avoidance of bedtime
Frequent requests after lights out
Refusal to go to bed or stay in bed

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17
Q

What is combined type of insomnia in children?

A

Both SOA and limit setting

Often difficulties with limit setting leads to development of negative sleep onset assoc.

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18
Q

What are contraindications to Extinction procedures?

A

Severe anxiety d/o
Children w/ past trauma
Prolonged crying is medically contraindicated (cardiac condition)

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19
Q

What percent of children experience bedtime problems and night awakenings?

A

20-30% of children experience bedtime problems and night awakenings

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20
Q

What is a sleep onset association in children?

A

Conditions that must be present to help a child fall asleep and return to sleep

Positive=one w/o assistance such as thumb sucking, pacifier, stuffed animals (able to self soothe)
Negative=another person, nursing, being rocked

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21
Q

General parent education

A

Night wakings are normal

Bedtime behavior problems are often difficult to manage

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22
Q

What is graduated extinction?

A

It is an effective treatment and often more tolerable for parents than standard extinction
Remove reinforcement over time
Treatment: putting to bed when drowsy and then checking in at regular intervals (fixed or incremental scale).
Not tied to whether child is crying
Problem as to whether you are still reinforcing in some way

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23
Q

What is Extinction with parental presence?

A

Ignoring the child’s crying but remaining near the child (in the same room).
Also called “parental presence” or “camping out”
Parent staying in child’s room, but not attending to them when crying

Other terms are “planned ignoring”
Parent is present; gradually fades involvement
Amount of physical contact
Proximity to infant

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24
Q

What is an Extinction Burst?

A

Reappearance of a previously extinguished behavior (crying)

It should be ignored to prevent the problem from reoccurring due to parental reinforcement

25
Q

What is the major barrier to implementing extinction treatments?

A

Parental resistance is the major barrier.

26
Q

What are alternatives to Extinction treatments?

A

Positive routines

Bedtime fading

27
Q

Normal sleep and development for newborns (0-3 months)

A

10-18 hrs/day (longer premature infants)
No designated sleep time (45 min-4hr) across 24 hr span
8-12 weeks, sleep patterns begin to consolidate, differentiation between day and night, more predictable sleep/wake schedule

28
Q

Normal sleep and child development for Infants (3-12 months)

A

12-13 hrs (9-10 hrs at night and up to 4 hrs during day w/naps)
Individual variability
Sleep consolidation continues
Most 6 month old sleep through night (at least 6-8 hrs) and 2-3 daytime naps

29
Q

Normal sleep and development for toddlers (12 mos - 3 yrs)

A

TST= 12-14 hrs
9-12 hrs at night, 2-4 hrs w/naps
By 18 months most toddlers have transitioned to 1 nap

30
Q

Normal sleep and development for Preschoolers (3-5 years)

A

Decreased sleep needs due to phasing out of daytime naps
Average 11-13 hrs of sleep per 24 hrs
by age 5, only 25% of children continue to nap during the day (increased napping in black children, possibly due to not enough sleep at night, socioeconomic reasons)

31
Q

How should a parent establish a sleep schedule and bedtime schedule?
What is Bedtime fading?

A

Ensure child is falling asleep at consistent and age appropriate time
7:30pm for infants
7:30-8:30 pm for toddlers/preschoolers
If child is put into bed at 7pm, but doesn’t fall asleep until 9pm; place child in bed at 9pm and slowly fade (add 15 min. Every 3-4 nights). This is Bedtime Fading
Keep consistent bed and wake up times
Consistent bedtime routines can reduce bedtime resistance and increase sleep consolidation (3-4 soothing activities that occur on nightly basis (bath, books, prayers, bed) for total of 30-40 min.
Consistent bedtime routine and sleep schedule is needed prior to continuing with graduated extinction

32
Q

Other factors involved in childhood sleep and using Extinction treatments

A

Stabilize parent behaviors and sleep location at bedtime and during the night
Set a global or targeted approach:
Based on child temperament and parent tolerance
Decide to do both bedtime and night awakening or one at a time
REsearch indicates that intervention at bedtime often transfers in 2 weeks time to night time awakenings
and targeted approach is usually more tolerated by parents

33
Q

How is Graduated Extinction implemented?

A

1-2 weeks of bedtime routine
Bedtime and parent behaviors have been consistent
Next step is to gradually remove the negative sleep onset association (e.g., nursing parent lying next to child)
Each step is followed for at least 3 nights, but more often 4-7 nights until behavior has stabilized
Problem-solve barriers to treatment adherence

34
Q

How is Positive Routines done as a procedure

Bedtime Routine

A

Involve positive and rewarding bedtime interactions with the caregiver
Help children to establish cues for sleep onset
Typical improvements within 1-2 weeks, treatment last 2-6 sessions

3-4 quiet activities, such as bath/washing, massage/lotion, stories, cuddling/rocking
No electronics
Same order and time each night.

Effective as stand alone intervention
Dose-dependent relationship

35
Q

What are the details of Bedtime Fading?

A

Start with initially later bedtime
Move it earlier slowly over time
Useful for settling problems
Move child’s bedtime to typical sleep onset time
Positive, quiet routines
After 2 nights, if child has SOL <15 min, advance bedtime by 15 min
If child has SOL>15 min, delay bedtime by 15 min.
Maintain regular rise time
Classical conditioning/sleep hygiene
Power struggles eliminated (child is exhausted at bedtime)
Can combine with standard bedtime routines and positive reinforcement to adjunct
For teens, use token economy to trade in for larger reward

36
Q

What are BSM principles for Bedtime fading?

A

Starting out w/initially later bedtime results in buildup of sleep pressure
Support behavioral strategies of removing parental involvement at sleep onset
Working toward more normal SOL of 20-30 min and determining need for sleep
Behavioral Tx works best when wake-up time is anchored.
An initial later bedtime is selected based upon when child is typically falling asleep (or within 30 min. Of this time)
Then bedtime is gradually moved earlier

37
Q

What is the Bedtime Pass?

A

Moore, 2007 journal of ped psychology
Child is given a “bedroom pass” with his/her name written on it that can be used for one brief trip out of the bedroom to get another hug, drink of water. The pass is surrendered to the parent when used
Behav. Med. Principles: the bedroom pass is used to set limits to “curtain calls” at bedtime or leaving the bedroom at wake-up’s to seek parental attention/comfort (limit setting)
The use of the pass just one time can be reinforced by child earning reward in morning (sticker, small prize from treasure chest) or a privilege (i.e. positive reinforcement)

38
Q

What is exposure with response prevention?

A

Backbone of anxiety interventions
Create hierarchy of anxiety-provoking steps toward going to bed and sleeping independently
Flashlight treasure hunts (fear of the dark)
Positive self-talk

39
Q

What is cognitive restructuring?

A 
Identify automatic thoughts
Look at evidence for and against that thought
Rate associated feeling and intensity
Other thoughts/helpful coping strategies
Rate feelings with new thought
40
Q

What is positive reinforcement (operant conditioning)?

A 
Behavior is encouraged by rewards
Positive punishment= an undesirable stimulus is introduced to discourage the behavior
Negative reinforcement= undesirable stimulus is removed to encourage the behavior
Negative punishment (extinction)= a desirable stimulus is removed to discourage the behavior
41
Q

How is the behavioral technique Scheduled Awakenings carried out?

A

It is a behavioral technique that is mostly successful in situations in which episodes occur (arousal d/o) on nightly basis
Children w/frequent d/o of arousal that occur highly predictive time, scheduled awakening can be highly effective
Involves having parent wake child ~15-30 min prior to time of night episode typically occurs
First keep sleep diary
Parent begins waking child on nightly basis just prior to event-just to point of arousal (e.g. child changes position or mumbles)
Do over 2-4 weeks

42
Q

Nocturnal enuresis

A

Common parasomnia affecting 5-7 million children annually- mostly inherited
15-20% of 5 yr old children
As many as 10% remain wet at 10 yrs old
Higher incidence for boys

43
Q

What is the best evidence based treatment for nocturnal enuresis

A

Moisture alarm

Indicated for children with primary enuresis (not fully continent for at least 6 mos)
Indicated for secondary enuresis (continent for 6+ months, but then relapse)
Most alarms are for 5+ yrs old

Treatment often deferred until 6-7
Enuresis shows steady decline w/age and has spontaneous remission rates of ~15%

44
Q

What medications are used for Nocturnal enuresis?

A 
Medication is not a front line treatment
Medications include:
	desmopressin
	tolerodine
	imipramine
	oxybutynin
45
Q

What are the intervention steps for evaluating nocturnal enuresis in children?

A 
Pick a right time by age
Prelim. Eval by MD: look for UTI, comorbid conditions (Diab insipidis, spina bifida, or spinal cord trauma
Education and demystification
Interview by behav. Health staff
Moisture alarm procedural checklist

Important supplies:
alarm that has a salient wake up cue
auditory alarms have most supportive data, vibrating alarms also effective
vibrating alarms may be preferred when share a bedroom

46
Q

What is Dry bed training for nocturnal enuresis?

A

Azrin
Inhibiting urination training
Positive reinforcement for correct urinations
Training in rapid awakening
Increased fluid intake vs fluid restriction
Increased social motivation to be non neurotic
Self-correction of accidents
Practice in toileting
Dry bed is considered 14 days

47
Q

What is systematic desensitization?

A

Develop a hierarchy of fear-invoking activities or thoughts from least to most frightening with the child
These activities or thoughts are paired with a relaxing activity

48
Q

What relaxation therapies are used in children?

A

Deep breathing
Biofeedback
PMR

49
Q

Newborn sleep characteristics

A

Sleep periods separated by 1-2 hrs of wake time
Cycles dependent on hunger/satiety
3 sleep states: Active (REM-like), Quiet sleep (non-REM like), Indeterminate
Enter sleep through Active (REM) state
Early weeks: no est. nocturnal/diurnal pattern
Immaturity of circadian sleep-wake cycle results in limited rhythmicity and predictability of sleep

50
Q

More info about sleep enuresis in children

A

Criteria: 2x/wk in a child +5 for at least 3 mos
Genetic component
Prevalence: 22% of 5yo, 10% of 6 yo, 1-3% of 15yo
15%/yr improve without intervention
Primary vs secondary
Assoc w/ reduced self-esteem, self-esteem increases with successful Tx
First line Tx: urine alarm

51
Q

Pediatric RLS- What’s different?

A

Children w/ untreated RLS may exhibit behaviors consistent w/ bedtime resistance
Lower prevalence: 1-6%
Increased prevalence in children w/ ADHD and ASD
Low iron storage (serum ferritin <50) found in 70-75% of children w/ RLS. Tx is iron supplementation
Child report: may include terms such as squeezing, tingling, wiggling, itchy, popping, “funny” feeling

52
Q

What is the BEARS clinical interview for children?

The Sleep Habits Assessment

A

Bedtime: routine, resistance, fears
EDS: hyperactivity, irritability, difficulty waking
Awakenings: call outs, partial arousal, restlessness
Regularity: schedule, duration
Snoring: volume, pauses in breathing

53
Q

AASM Clinical practice Guidelines

Practice parameters for behavioral Tx of bedtime problems and night wakings in infants and young children

A

Behavioral interventions are effective and recommended in the tx of bedtime problems and night awakenings in young children. (Standard)

54
Q

Extinction Txs are effective

A 
Infant and child outcomes:
Did not negatively impact breastfeeding or infant daily intake.
Reduced crying after intervention
Reduced irritability
More predictable schedule
Better overall behavior
Parent and family outcomes:
Fewer nightwakings
Improved mood
In depressed mothers, reduced sx
Enhanced marital satisfaction
Reduced parenting stress
Increased parenting efficacy
55
Q

Faded bedtime with response cost

A

Temporarily delaying a child’s bedtime to closely coincide with their typical sleep onset time
Based on principles of stimulus control
bedtime is faded earlier as child falls asleep faster until a target bedtime is reached
Typical rate 15-30 min. Per night
Response cost involves taking the child out of bed for short periods if not falling asleep

56
Q

The Bedtime Pass, other aspects

A

Bedtime Pass is a card exchangeable for one parental visit or excused departure from the room after bedtime

Subsequent bids for attention are ignored

Evaluated by in 3-6 year olds and found to be effective in reducing “curtain calls” and SOL

Recommended for ages 3-10

57
Q

What is Alarm therapy?

A

Bed wetting alarm, urine alarm, bell and pad
Alarm alerts child in response to moisture, child leaves bed to finish urinating in bathroom
May require practice to learn to wake in response to alarm.
Widely recognized as optimal Tx for enuresis
Superior to medication and psychological intervention
Success rate 78% when used for 4-6 mos
25-40% relapse

58
Q

Dry Bed Training, details

A 
Azrin, 1974
Treatment components:
Positive practice
Increased fluid intake
Scheduled awakenings
Alarm
Positive reinforcement
Cleanliness training

Phases:
Intensive training (one night, hourly awakenings)
Post-training supervision (ongoing, scheduled awakenings)
Normal routine (after 7 dry nights, only positive reinforcement and cleanliness training)

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