Exam 1 Flashcards
(43 cards)
1
Q
Clinical Problems
A
- Behaviors or thoughts that someone identifies to be debilitating, harmful or nonfunctional for the individual.
- 20% of youth estimated to have clinic-level disorders, with 10% being significantly impaired.
2
Q
Evidence-Based Practices
A
-APA code of ethics states psychologists are required to integrate best available practices within the context of clients’ characteristics, culture and preferences when implementing treatment.”
-SAMHSA’s National Registry of Evidence-Based Practices (NREPP) – an online registry of more than
190 interventions supporting mental health promotion through validated treatments.
3
Q
Psychological Settings
A
- Community Mental Health Centers
- State supported, sliding scale/sometimes indigent, pathologies vary and often serious.
- Outpatient Private Practice
- The therapist makes a living of whoever pays the most.
-Shared Private Practice (consortium)
-It is cost effective, because the therapists share costs and expenses. Ei: use same space,
receptionist, etc.
- Inpatient Psychiatric Hospital
- Units: adolescent, adult, eating disorders, substance abuse, gerontology, mood disorders, psychotic
- Positions: mental health tech, therapist, psychologists, psychiatrists, physicians
- Medical Hospitals (in/outpatient)
- Units: oncology, diabetes, asthma, general/adolescent or pediatric
-Patient Homes (CPS)
4
Q
Clinical Considerations in Treatment of Children
A
- People differ in their perspectives as to what is problematic.
- Opinions vary across cultures, between families, differs across the child’s social and cognitive development
- Appreciate the perspective of others.
- Problems are multi-determined
- Need to ameliorate problems so everyone is satisfied & problems don’t recur.
- The therapist takes on the role of a diplomat.
- Problems in family members are inter-related.
- Limited when only talking to a child:
- 1) Teach a child how to react to a certain situation in the family.
- 2) The child implements new reaction & parent acts without new knowledge or understanding of child’s intentions.
- 3) The child’s response may create a new unprepared situation.
5
Q
Problems in Family Members are Inter-Related (Part of “Clinical Considerations In Treatment of Children)
A
- Problems in family members are inter-related.
- Limited when only talking to a child:
- 1) Teach a child how to react to a certain situation in the family.
- 2) The child implements new reaction & parent acts without new knowledge or understanding of child’s intentions.
- 3) The child’s response may create a new unprepared situation.
6
Q
Hallmarks of Behavioral Therapies
A
- Focus on establishing skills and accomplishing mutually-determined goals.
- Change ways child & others think/behave, such that child and others in system receive more Sr+
- Use lots of descriptive praise, pats on back, snacks/sodas (make therapy reinforcing)
- Tx. includes all relevant family & friends of child.
- Time spent w/ child individually, parent(s) individually, and together
- Role-playing extensively used to teach new skills
- Practice better memorized
- Follow agendas & treatment manuals
- Take the time to be prepared for your clients!
- Include rationales for selected treatments
- Discuss etiology, prevalence, and expected outcome
- Explain why intervention is expected to be successful for the particular person
- Build motivation to conduct intervention
-Use therapy assignments
7
Q
Functional Analysis
A
- Step 1: Determine the problem
- a) Interview
- b) Patient records
- c) Standardized self-report measures
- d) Behavioral observation
- e) Role-playing
- Step 2: Understand why the problem occurs
- Rely on ABC model to guide intervention
- Antecedent, Behavior, Consequence
- Antecedent = Instructions to do homework
- Behavior = Yelling
- Consequence = Talking softly, rubbing pt’s back, etc.
- Rely on ABC model to guide intervention
Step 3: Develop Treatment Plan
-Ask what family was hoping to learn from assessment
8
Q
Oppositional Defiant Disorder (ODD) Criteria
A
- Pattern of angry/irritable mood, argumentative/defiant behavior, or vindictiveness lasting at least 6 months as evidenced by at least 4 symptoms from any of the following categories, and exhibited during interaction with at least 1 individual who is not a sibling:
- Often loses temper
- Is often touchy or easily annoyed
- Is often angry and resentful
- Often argues with adults
- Often actively defies or refuses to comply with requests from authority figures or with rules
- Often deliberately annoys others
- Often blames others for his or her mistakes or misbehavior
- Has been spiteful or vindictive at least twice within the past 6 months
- Onset prior to 18 yrs.
- 6-11% in nonclinic samples
- > males than females prepuberty, = thereafter
- 1/3 to ½ of all referrals to outpatient & inpatient child mental health clinics
9
Q
ODD: Etiology
A
- Harsh, poor, and inconsistent discipline
- Child Maltreatment
- Lack of parental warmth and involvement
- Maternal Depression
- Parental antisocial behavior
- Marital conflict.
- Lack of parental monitoring
- Poor Social Skills
- Antisocial peers
- Rejection by peers
- Lack of involvement in appropriate social activities
- Early substance abuse
- Impulsivity.
- Poor school performance
- Learning disabilities
- Lower than avg. IQ,
- Genetics, i.e., attentional and impulse control deficits,
- Temperamental difficulties when an infant,
- Hostile attributional biases when interpreting social cues,
- Negative coercion,
- Higher levels of stress,
- Isolation from others, i.e., insularity
10
Q
Conduct Disorder (CD) DSM Criteria
A
- DSM V Criteria Repetitive and persistent pattern violating rights of others, as manifested by 3 or more of the following symptoms in the past 12 mos (=>1 in the past 6 mos:
- Prevalence for CD is 12% for males
- Prevalence for CD is 7% for females
- Aggression to people and animals
- Often bullies, threatens, or intimidates others
- Often initiates physical fights
- Has used a weapon that can cause serious physical harm to others (e.g., a bat, brick, broken bottle, knife, gun)
- Has been physically cruel to people
- Has been physically cruel to animals
- Has stolen while confronting a victim (e.g., mugging, purse snatching, extortion, armed robbery)
- Has forced someone into sexual activity
- Destruction of property
- Has deliberately engaged in fire setting with the intention of causing serious damage
- Has deliberately destroyed others’ property (other than by fire setting)
- Deceitfulness or theft
- Has broken into someone else’s house, building, or car
- Often lies to obtain goods or favors or to avoid obligations (i.e., “cons” others)
- Has stolen items of nontrivial value without confronting a victim (e.g., shoplifting, but without breaking and entering; forgery)
- Serious violations of rules
- Often stays out at night despite parental prohibitions, beginning before age 13 years
- Has run away from home overnight at least twice while living in parental or parental surrogate home (or once without returning for a lengthy period)
- Is often truant from school, beginning before age 13 years
- The disturbance in behavior causes clinically significant impairment in social, academic, or occupational functioning.
- If the individual is age 18 years or older, criteria are not met for Antisocial Personality Disorder
11
Q
CD: Etiology (see ODD for others)
A
-Child abuse
- Family conflicts
- Lack of parental warmth/involvement
- Genetic defects
- Maternal depression
-Parental drug addiction/alcoholism
- Poverty
- Maltreatment
- Harsh, poor, and inconsistent discipline
- Child Maltreatment
- Lack of parental warmth and involvement
- Maternal Depression
- Parental antisocial behavior
- Marital conflict
- Lack of parental monitoring
- Poor Social Skills
- Antisocial peers
- Rejection by peers
- Lack of involvement in appropriate social activities
- Early substance abuse
- Impulsivity
- Poor school performance
- Learning disabilities
- Lower than avg. IQ,
- Genetics, i.e., attentional and impulse control deficits,
- Temperamental difficulties when an infant,
- Hostile attributional biases when interpreting social cues,
- Negative coercion,
- Higher levels of stress,
- Isolation from others, i.e., insularity
12
Q
ODD/CD: Comorbid Disorders
A
- Associated Characteristics:
- Cognitive & verbal deficits (ADHD, lower IQ)
- School & learning problems
- Self-esteem deficits
- Peer problems
- Family discord
- Health-related problems (homicide, suicide)
- Comorbid Disorders:
- ADHD
- Depression & anxiety
13
Q
ODD/CD: Interesting Facts
A
- Due to the similarity between ODD and CD, they share many of the same etiologies
- About 1/3 of those with ADHD are diagnosed with conduct disorders
- CD and ODD make up 1/3 of childhood disorders
- CD is a predictor for spousal abuse
14
Q
Interventions: Hanf-Forehand Model (ODD and CD?)
A
- Phase one:
- Parent it taught to attend (e.g., being eye level, tone of voice, pats on back, describe desired behaviors to kid) to child’s desired behaviors, while eliminating commands, questions, and criticism.
- Parent is taught to praise desired behaviors and ignore undesired behavior,
- Undesired behaviors can be ignored if no property damage/risk of damage and no harm or risk to the child or others.
- Homework to practice skills in 10 minute interactions with child per day.
- Parent is taught to praise desired behaviors and ignore undesired behavior,
- *Monitoring Chart for Attends (separate flashcard)
- Phase two:
- Parent is taught to make appropriate commands (i.e., please, specific, to the point)
- Parent is taught to use time out.
- State directive e.g., John, Turn off the television, now. (wait five seconds for child to comply)
- Repeat directive with warning to go to time out for 1 min./yr-age (wait 5 sec. for child to comply).
- Direct to TO if child does not comply
- Parent is taught to use time out.
15
Q
Monitoring Chart of Attends
A
- Action:
- Desired Behavior
- How did I attend?
- How did my child respond?
-Every day of week is listed
16
Q
Patterson’s Social Learning Model (ODD and CD?)
A
- For children 8-12 years
- Assign parents to read “Living with Children” or Families
- Teach parents to track 2 or 3 problem behaviors for a 1 hr. period each week
- Teach parents to target problem behaviors with (1) praise and (2) a point system
- Points are awarded for performance of desired behaviors, and subsequently exchanged for reinforcers
- Point systems have monitoring charts to record desired behaviors, points earned, points exchanged for rewards, and menu of reinforcers
- 5-minute time out for aggression or noncompliance after pt. system is established.
- Response cost (take away privilege)
- Problem-solving and negotiation strategies for parents and kids
- About 30% of time allocated to working w/ parents on marital difficulties, individual problems, etc.
- Teach parents to monitor youth behavior.
- In lieu of time out, kids lose points, free time, and must perform restitution for stolen/damaged property
- Greater involvement of adolescent in sessions re. formulation and monitoring of contracts.
-*Look at chart on slide 18
- Ex:
- Reward Menu:
- Favorite Dessert (reward) = 1 Point (cost)
- Ability to Watch Television (reward) = 2 Points (cost)
- Attend Movie Theater (reward) = 7 Points (cost)
- Reward Menu:
17
Q
Other Treatment Methods (for ODD and CD?)
A
-Positive Practice
- Problem-solving skills training
- Problem identification
- Generation of solutions
- Review of solutions
- Solution enactment/Sr+
- BT and CBT
- Social Skills Training
- CM (Quid pro quo, point systems, level systems)
- Communication/social skills training
- Multi-systemic therapy
- Parenting Wisely
- Family behavior therapy
- CRA-A (com. guidelines, reciprocity awareness, positive request, contracting, etc.)
- Teaching Family Model
- Most researched of all inpt. Programs
- 250 group homes
- Teaching parent sets rotate to run home
- 5-8 adolescents in each home
- Level system
- Self-government (daily family conferences, peer manager)
- Home-based token economy (school-based)
- Avg. stay is 1 year
18
Q
Description of Disorder: Substance Use Disorder
A
- At least 2 of the following in past year:
- Tolerance
- Withdrawal
- Taken in larger amounts or longer time than intended
- Persistent desire or unsuccessful efforts to cut down
- Great deal of time spent trying to get the substance
- Craving, or a strong desire or urge to use substance
- Continued use despite having persistent or recurrent social problems caused or worsened by substance effects
- Important activities given up because of the substance
- Use in situations that are dangerous
- Use despite physical or psychological problem caused by substance
19
Q
Other Diagnostic cIssues with Substance Use Disorder
A
- Often lack motivation
- Use motivational interviewing methods
- Consequence Review intervention
- Initial Rating: 0 = not at all unpleasant; 100 = completely.
- Initial Unpleasant Consequences
- Prompted Unpleasant Consequences
- Post-Rating: 0 = not at all unpleasant; 100 = completely
- Review/Empathize
- Review Positive Consequences
- Abstinence vs. controlled
- Attempt abstinence & utilize shaping if refusal.
- Probs. detecting drug use
- Urine drug screens last only a few days, in general
- Don’t worry about detection, target things you can see
20
Q
Prevalence of Substance Use Disorder
A
- In school-based services during past year, 16%;
- Boy to girl ratio = 5:1 for alcohol
- About equal for other drugs & changing rates
21
Q
Substance Use Disorder - Etiologies
A
- Modeling by peers/ parents
- Relieves stress/ anxiety
- Genetics
- Low self-esteem
- Positive expectancies of use
- Poor problem solving and coping skills therefore may use drugs to take away aversive events/ circumstances
- Easy access
- Lack of goals
- Parental neglect and abuse
- Poor impulse control
- Sensation seeking tendencies
- Familial stress and conflict
- Externalizing disorders
- Parental hostility and lack of warmth
- Lack of parental support
22
Q
Substance Use Disorders - Treatment Approaches
A
- Functional Family Therapy
- Family Behavior Therapy
- Contingency Management
- Multi-Systematic Therapy
- Brief Strategic Family Therapy (BSFT)
23
Q
Functional Family Therapy (SUD)
A
- Introduction/Impression phase
- Focused on family members’ expectations prior to therapy
- Assessment phase
- Identification of behavioral, cognitive, and emotional expectations of each family member, and family processes in need of change (e.g., closeness and distance)
- Induction/therapy phase
- Modify inappropriate attributions and expectations of family members using cognitive techniques (e.g., relabeling negative behavior in benevolent light by describing its positive antonym, portraying family members as victims and not perpetrators)
- Behavior change/education phase
- Employment of behavioral techniques (e.g., communication training, contracting)
- Generalization/termination phase
- Foster independence of family from therapy
24
Q
Family Behavior Therapy (SUD)
A
- Motivational Exercises
- Level System
- Treatment Plan
- Stimulus Control
- Self-Control
- Communication Enhancement
- Positive Request
- Job-Getting
- Concluding Treatment and Generalizing Results
25
Contingency Management (SUD)
- Community Reinforcement Approach w/ Vouchers
- Family Behavior Therapy
- CBT (Kathleen Carroll)
26
Multi-Systemic Therapy (SUD)
- Hand school-based
- Family-based (everyone)
- Harm reduction-based
- Marital therapy employed
- Individual therapy
- Contingency contracting
- Self-instructions
- 9 tx. principles (focus on systemic strengths, increase responsible behavior in family, developmental appropriateness)
27
Brief Strategic Family Therapy (BSFT) (SUD)
- Sessions conducted at locations convenient for family (e.g., family's home).
- Designed for Hispanic families in particular.
- Adolescent symptomatology rooted in maladaptive family interactions, inappropriate family alliances, overly rigid or permeable family boundaries, and parents' tendency to blame adolescent for family's troubles.
- Strategies include joining and strategically helping family to restructure themselves.
28
Description of ADHD
- 3 Types of ADHD:
- 1. Attention Deficit/Hyperactivity Disorder, Combined Type
- 6 symptoms of inattention & 6 symptoms of hyperactivity/impulsiveness for at least 6 months (5 for adults)
- 2. Attention Deficit/Hyperactivity Disorder, Predominantly Inattentive Type
- 6 symptoms of inattention (less than 6 symptoms of hyperactivity) for at least 6 months
- 3. Attention Deficit/Hyperactivity Disorder, Predominantly Hyperactive-Impulsive Type
- 6 symptoms of hyperactivity/impulsivity (less than 6 symptoms inattention) for at least 6 months
- ADHD symptoms include:
- Inattention (careless errors, not paying attention, not doing instructions, forgetful, distracted by irrelevant details)
- Hyperactivity (fidgeting, running excessively, trouble playing quietly, talking too much)
- Impulsivity (not waiting turn, interrupting others, blurting out answers)
- Some symptoms before 12 yrs.
- Symptoms must be developmentally inappropriate
- Some symptoms in at least 2 settings
- Not due to other mental disorder
29
ADHD - Prevalence
- 5-8% school-age kids; 4% take ADHD meds.
- From 4:1 to 9:1 males: females
- Children w/ ADHD are up to 3 Xs more likely to use, abuse or become dependent illicit drugs.
30
ADHD - Etiology
- Deficiencies of neurotransmitters norepinephrine and dopamine, and possibly serotonin
- Abnormal interactions between cortical and sub cortical structures in frontal lobe
- Toxic or allergic reactions to foods
- High co-morbidity w/ other externalizing disorders
- Single gene associated with dopamine transport
- Poor child management and monitoring skills
- Family conflict
31
ADHD - Intervention Approaches
- Stimulant medication
- Methylphenidate (Ritalin), d-amphetamine (Dexedrine) or drug w/ similar structure Adderral
- Higher doses of Ritalin to reduce hyperactive symptoms
- Lower doses to reduce symptoms of inattention
- Effects on behavior within 30-45 mins., peak within 2-4 hours, lasting up to 7 hours
- Prescribed 2 or 3 times/day, now these stimulants have slow releasing capsules to reduce # of administrations
- Drug holidays
- Ritalin does not significantly retard growth
- Side effects: mild insomnia, appetite reduction, irritability/crying for some when med. effects wash out, headaches, stomachaches.
- Outcome studies indicate effects of stimulants are best tx
- Tricyclic Anti-depressants
- Imipramine and desipramine
- Low doses may mimic effects of stimulants, and assists in elevating mood
- Effects of these meds. diminish over time
- Side effects: drowsiness in 1st few days, dry mouth, constipation, possible tachycardia or arrhythmia, rash.
- Child Management Skills Training
- Contingency Management
- Home-based token economy
- Identify target behaviors at school
- Make arrangements for child to bring home teacher’s evaluation of target behaviors (monitoring form)
- Teacher(s) should sign
- Forgetting form should result in negative consequence
- Self-instructional training
- Teach child to employ self-instructions
- Assign homework to monitor self-instructions
32
Major Depression
- (5 or more at least 2 weeks, need depressed mood or loss of interest)
- Depressed mood most day, nearly every day (can be irritability in children)
- Sign. loss interest/pleasure in normal activities
- Reduced sex drive
- Insomnia or excessive sleeping
- 5% loss of body weight when not dieting (or not making developmental gains in children),
- Insomnia/hypersomnia nearly every day
- Agitation or restlessness nearly all day
- Fatigue or loss of energy nearly every day
- Feelings of worthlessness or guilt, fixating on past failures or blaming yourself when things aren't going right
- Trouble thinking, concentrating, making decisions and remembering things nearly all day
- Frequent thoughts of death, dying or suicide
- Symptoms cause sig. distress or impairment in functioning
- Not due to effects of substance or medical condition
33
Dysthymia
- Depressed mood or irritability (in kids)most of day, more days than not for 1 yr (2 yrs. in adults).
- 2 of the following: poor appetite or overeating, insomnia or hypersomnia, low energy/fatigue, poor concentration, low self esteem, hopelessness.
- Never without symptoms for more than 2 months during the yr. for kids (2 years for adults).
- Major depression may be continuously present*, never manic/hypomanic episode, or schizophrenia or other psychotic disorder, causes distress or impair.
- Life time prevalence: 6%, point prevalence: 3%
34
Major Depression (and Dysthymia?) - Diagnostic Issues and Prevalence
- Diagnostic Issues
- Conduct problems often mask signs of depression
- Children have a hard time articulating thoughts and feelings
- Suicide has increased for children (although rare) and adolescents.
- White male adolescents are most at risk to complete task via firearms.
- Prevalence
- 1% in preschool children
- 3% in 6-11yr. Olds
- 6-8% in adolescents
- 5-12% for adult men
- 10-25% for adult women
- Affects pre-puberty males and females equally
- About 5:1 female to male ratio in adolescents
35
Major Depression and Dysthymia - Etiologies
- Genetics
- Low-levels of serotonin, norepinephrine and other neurotransmitters – which increase memory.
- Negative automatic thoughts
- Perceive negative events as internal, global, and stable
- Attend to neg. aspects of an event or circumstance
- Set unrealistic goals
- Insufficient self-rewards
- Poor social skills lead to inabilities to obtain reinforcement from environment,
- Poor problem-solving skills relevant to social situations
- Lack secure attachments
- Lack social support
- Stress
- Stress is body's reaction to changes that require physical, mental, or emotional adjustment.
- Stress triggers anxiety and negative automatic thoughts.
- Setting unrealistic goals, insufficient self-rewards, and having poor social skills lead to inabilities to obtain reinforcement from environment.
- Poor problem-solving skills in social situations and lack of secure attachments/support leads to insecurity and odd behaviors.
36
Major Depression and Dysthymia - Treatment Approaches
- Problem-solving skills training
- Social/communication skills training
- Coping with depression course
- Relaxation skills training
- Pleasant activities scheduling
- Cognitive restructuring
- Combined CBT and Drugs
37
Problem-Solving Skills Training (Treatment Approach for Major Depression and Dysthymia)
- Negotiation & Problem-Solving Skills Training
- Problem identification (clearly and succinctly stating the problem)
- Solution generation
- Review pros & cons of each solution
- Decide on best solution and try it (solution enactment)
- Self-evaluation/self reinforcement (optional step)
- Use w/ games 1st, then academic problems, then social situations
38
Social/Communication Skills Training (Treatment Approach for Major Depression and Dysthymia)
-Common target areas: assertiveness, communication, accepting and giving feedback, conflict resolution, disclosure, listening, entering and leaving conversations, compliments, expressing neg. feelings.
- Teaching method:
- Introduce skill (possibly w/ example)
- Provide problem scenario relevant to skill
- Brainstorm skills that might work to solve problem
- Attempt skill set as model
- Review things model did well (possibly enhancements)
- Instruct child to role-play w/ provider
- Make easy scenario and progressively get harder
- Provide lots of descriptive reinforcement
- Solicit things child thinks might enhance performance
39
Coping with Depression Course (Treatment Approach for Major Depression and Dysthymia)
- Adolescent Coping with Depression Course (CWDA; Lewinsohn)
- Child, parent, and parent/child sessions
- Designed to help parent support and reinforce efforts of children
- Affective training (e.g., review feelings in pictures in magazine)
- Brainstorm “showing people you are a friendly person”
- Assign to have specified conversations w/ other kids
- Show how feelings/emotions, actions, and thoughts are related.
- Use triangle w/ behaviors, feelings, thoughts
- Behaviors and thoughts can optimize positive feelings
- Easier to change actions and thoughts to influence emotions.
- Self-monitoring of daily mood ratings (1=very sad, 7=very happy)
40
Relaxation Skills Training (Treatment Approach for Major Depression and Dysthymia)
- PMR (Jacobsen)
- Alternate tensing (12 secs.) and relaxing (6 secs.) for each major muscle.
- Fade out tension component.
- Use animal or cartoon character symbolism w/ younger kids.
- Fill up like a blowfish, make muscle like Popeye.
- Cue-controlled relaxation (Benson technique)
- Assist child in imagining relaxation scene while therapist provides cues.
- e.g., beach scene, woods
-Assign homework to practice relaxation at home in bed at night.
41
Pleasant Activities Scheduling (Treatment Approach for Major Depression and Dysthymia)
- Establish realistic goals to engage in pleasant activities.
- Warm-ups w/ kids exchanging positive things about each other
- Start by asking, “Are mood and pleasant activities related?”
- Help kids to establish their own rewards for having completed self-assigned pleasant activities
- Use a generic list of fun activities
42
Cognitive Restructuring (Treatment Approach for Major Depression and Dysthymia)
-This treatment involves identification and modification of negative thoughts into positive and/or neutral thoughts.
- Review common types of negative thinking while soliciting youth experiences w/ them:
- Magnification: blowing an issue out of proportion (e.g., overly upset over pimple).
- All or none thinking: thinking in absolute terms (either a friend or enemy, good or bad).
- Selective abstraction: concluding on certain details, while ignoring others
- People won’t like me if I don’t give them my answers to the test.
- Personalization: over-interpret events related to self in the negative.
- Kids walk by and laugh, so the kids must be laughing at me
- Identify activating events that lead to negative thoughts
- Identify how to change negative thoughts into positive or neutral alternative thoughts
- Kids also review coping skills to deal with activating event/trigger
- Schedule “worry time”
- Thought stopping (snapping rubber band) for negative thoughts
43
Combined CBT and Drugs (Treatment Approach for Major Depression and Dysthymia)
- Combined Cognitive Behavioral Treatments
- Pleasant activities scheduling w/ family and peers
- Social skills training
- Problem-solving training
- Self-instructional training to assist in inattention
- Relaxation training combined with positive imagery
- Cognitive restructuring
- Psychopharmacological Drugs
- Include imipramine, fluoxetine, desipramine
- Side effects: potential permanent neg. effects in growth and IQ, variability in heart rate, dry mouth, reduced thresholds for seizures, death, sedation, blurred vision, constipation, headaches, abdominal pain, vomiting.
- Efficacy weak for children and young adolescents, and potentially dangerous in these populations.
