Developmental disabilities and peds MH Flashcards
What is the significance of testing for an ASO titer when diagnosing developmental disorders?
Can be helpful in diagnosing OCD
- Blood test to measure antibodies against streptolysin O (substance produced by group A streptococcus bacteria)
- Rules out PANS/PANDAS (associated with strep infection)
True/false: Persistent anxiety at high levels can cause maladaptive behaviors
True - warrants diagnosis and treatment
Symptoms suggestive of an anxious response
- Tachycardia
- Tachypnea
- HTN
- GI distress
- Tremor
- Sweating
- Enhanced vigilance and reactivity
Common pediatric anxiety disorder examples
- Separation anxiety
- Generalized anxiety
- Social anxiety
- OCD
- Agoraphobia
- PTSD
What three anxiety disorders are considered the pediatric anxiety disorder triad?
Happens in the same individual, have similar life courses and treatments
- SAD
- GAD
- Social anxiety
What is important to assess for in pediatric patients who present with anxiety?
Watch out for evidence of physical trauma
At what age does separation anxiety disorder normally present in pediatric patients?
Normal development phenomenon from 7 months old through preschool
- Manifests from 5-16 years (mean age 9 years)
Clinical findings associated with separation anxiety?
- Excessive anxiety r/t separation
- Unrealistic worry about harm to self or loved ones
- Nightmares about separation
- Physical complaints in anticipation of separation
- Social withdrawal during separations
- Environmental stress
Separation anxiety puts children at risk for what two disorders later in life?
Panic disorder and depression
Is pharmacology useful in managing separation anxiety?
Pharmacology is NOT helpful
- Best treated as family system or relationship based problem (psychotherapy)
What is generalized anxiety disorder?
Cognitive and obsessive in nature
- Cause excessive anxiety, worry, apprehension generalized to a number of events or activities
Generalized anxiety disorder clinical findings
- Worry about future events and/or preoccupation about past behavior
- Poor sleep
- Unexplained fatigue
- Irritability
- Difficulty concentrating
- Somatic complaints
What medications should NOT be prescribed to pediatric patients with GAD?
Benzodiazepines
- Should be treated with SSRIs (sertraline, fluoxetine), SNRIs (venlafaxine, duloxetine), buspirone
True/false: Preschoolers benefit from play therapy for GAD management
True
How long do symptoms need to be present in order to be diagnosed with PTSD?
One month or longer
Pediatric PTSD management
- Referral to pediatric behavioral health specialist
- Psychotherapy
- Medications
- Beta blockers (propranolol) for tachycardia and hyperpnea
- SSRIs for anxiety and depression
What are three categories of depression?
- Major depressive disorder
- Dysthymic disorder
- Adjustment disorder with depressed mood
What is major depressive disorder?
Depressed or irritable mood or markedly diminished interest and pleasure in almost all of usual activities for at least 2 weeks
- No precipitating event necessary
What is dysthymic disorder?
Depressed or irritable mood for the majority of days in the past 2 years that is less intense but more chronic than MDD
What is adjustment disorder?
Occurs within 3 months after major life stressor
- Episode is mild and brief
Clinical findings of depression in infants
May not respond to extra efforts to soothe or engage them
Clinical findings of depression in young children
- FTT
- Speech and motor delays
- Repetitive self soothing behavior
- Withdrawal from social interactions
- Poor attachment
- Loss of developmental skills
Clinical findings of depression in toddlers and preschoolers
- Lack energy
- Too eager to peals others
- Clingy
- Whiney
- Developmentally inappropriate problems with separation
Clinical findings of depression in school aged children
- Decreased mood
- Impaired concentration
- Inattention
- Irritability
- Fluctuating mood
- Temper tantrums
- Social withdrawals
- Somatic complaints
- Agitation
- Separation anxiety
- Behavioral problems
What essential diagnostic labs should be ordered for patients with new symptoms of depression?
- CBC
- EBV titers
- Vitamin D
- TSH
- Hcg
- UA
- Drug screen
Depression management
- Non pharmacologic therapy
- Determine suicidal risks and intervene
- Referral to community resources and behavioral health specialist
- Follow up in three months if symptoms are stable
Depression management
- Pharmacologic therapy
CBT + SSRIs (avoid paroxetine)
- Start antidepressants low and increase dose slowly
- Can take 4-6 weeks to see max response
What medications should be avoided in pediatric patients when treating depression?
- TCAs - avoid in young children (risk of harm)
- Paroxetine - avoid in children and adolescents (suicide risk)
- Atypical antidepressants can cause metabolic disorders
Signs and symptoms of serotonin syndrome
- Mental status changes
- Agitation
- Autonomic instability (HR, BP, sweating)
- Neuromuscular changes (poor muscle coordination, twitching, rigidity)
What is bipolar disorder?
Unusual shifts in mood, energy, functioning
- May begin with manic, depressive, or mixed set of manic and depressive symptoms
Signs of a manic episode in bipolar disorder
- Irritable mood and grandiosity
- Elevated mood
- Decreased sleep
- Racing thoughts
- Poor judgement
- Flight of ideas
- Hyper sexuality
What essential labs should be collected for symptomatic patients with bipolar disorder?
- CBC
- CMP
- TSH
- Toxicology screen
Bipolar disorder management considerations
- Promote patient safety (highest risk of suicide)
- Referral to behavioral health provider
- Mood stabilizers (lithium) alone or in combination with anti seizure medications (valproate) + atypical antipsychotics (risperidone)
What two medications are NOT effective in patients with bipolar?
Antidepressants and stimulants
ADHD clinical findings
- Inability to sustain attention, curb activity level, or inhibit impulsivity
- Concerns r/t memory, emotional control, organization, planning
- Inhibiting thoughts or actions
- Difficulty with peers, following rules and regulations
Important diagnostic/screening tools needed to diagnose ADHD
- Screen for iron deficiency, lead, thyroid dysfunction
- Screening tools
- Vanderbilt ADHD Scales
- ADHD rating scale IV
- Conner Parent and Teacher rating scales
- Child attention profile
ADHD management
- Non pharmacologic therapy
- Family education and support
- Behavior management alone
- For children < 6 years old and/or have mild symptoms
- First line therapy
ADHD management
- Pharmacologic therapy
- Stimulants → methylphenidate (Ritalin)
- Amphetamine (adderall, focalin, vyvanse)
- SNRI (strattera)
- Alpha adrenergic agonist (guanfacine, clonidine)
If a provider is going to start a patient with ADHD on a stimulant, what will it be important to screen for prior to therapy?
CV disease risk
- Collect family history
- Check if they are obese, have DM, dyslipidemia
- History of stroke, MI, TIA
What is the only stimulant for ADHD therapy that is approved for children <3 years old?
Amphetamine (adderrall)
- Therapy can cause patients to develop a tic, but most go away within 1 year
- Give more snacks for nutrition
What SNRI drug is approved for children >6 years old for ADHD treatment?
Strattera/atomoxetine - non controlled substance approved for children >6 years old
- Takes up to 6 weeks of regular use to notice effects
True/false: Patients with anorexia and bulimia are often underweight
False
- Anorexia = underweight
- Bulimia = average weight or overweight
Clinical findings for patients with eating disorders
- Menstrual irregularities
- Body dysmorphism
- Preoccupation with food
- History of dieting
- Guilt about eating
- Lies about eating or having eaten
- Social isolation
- GI symptoms
- Syncope
- Substance abuse
- Family history of chaos and abuse
Physical exam findings in patients with eating disorders
- Altered growth
- Parotid gland enlargement
- Fluid retention
- Thin body type
- Hypotension
- Dental erosion
- Thin hair, lanugo
- Muscle atrophy
- Lethargy
How much weight should a patient with an eating disorder gain per week while refeeding?
Weight gain during refeeding should be 1.1 pound/week
- Monitor for refeeding syndrome → confusion, irritability, organ dysfunction, seizure
Clinical findings suggestive of Down syndrome
- Short stature
- Brachycephaly - flat head
- Midface hypoplasia with flat nasal bridge
- Brushfield spots
- Epicanthal folds with up slanting palpebral fissures
- small mouth with protruding tongue
- Myopia, cataracts
- Small ears, narrow canal
- Extra skin at nape of neck
- Single palmer crease
- Clinodactyly - abnormally bent or curved finger
