Final Exam: Lectures (Mod 6/7) Flashcards
Theory of development:
Children gradually acquire the ability to understand the world around them through active engagement with it
Piaget’s theory/intellectual development
Theory of development:
Development occurs as a series of stages influenced by interpersonal connections
Freud and Erikson
Definition:
Repertoire of traits with which a child is born
Temperament
Can temperament be changes or adjusted?
Yes it can be modified by the interaction with caregivers, peers, their environment
-Biological influences
-Psychosocial factors
-Family history
-Genetics
-Effects of parental depression
-Stressful life events
-Childhood maltreatment
-Peer and/or sibling influences
Risk factors for the development of childhood mental health disorders
Child, parent, teachers, care providers, medical records, neuropsychological testing
Sources for gathering information about the child’s well-being
Most common disorder of childhood
Boys > girls
Generally diagnosed prior to age 7
S/S occurring for at least 6 months
Increased risk of conduct disorder, anxiety, depression, learning disabilities
ADHD
Symptoms:
Attention problems
Distractibility
Impulsive behaviors
Hyperactivity
ADHD
6 y/o M presents to the office today with his father. Dad reports ongoing concern for inconsistency with homework, trouble concentrating during baseball practice, and often having to repeat instructions to the child to get him to complete a task. The child’s last report card noted the child is talkative in class and is often needing to be reminded to sit in his seat and not talk when the teacher is talking. Dad initially thought this was just “boys being boys” but wants to confirm. You complete a Vanderbilt Rating Scale with concern for:
ADHD
6 y/o M presents to the office today with his father. Dad reports ongoing concern for inconsistency with homework, trouble concentrating during baseball practice, and often having to repeat instructions to the child to get him to complete a task. The child’s last report card noted the child is talkative in class and is often needing to be reminded to sit in his seat and not talk when the teacher is talking. Dad initially thought this was just “boys being boys” but wants to confirm. A tool you can have dad complete today and send a copy home with the family to be filled out by the child’s teacher is:
Conner’s Parent/Teacher Rating Scales
After investigation, you diagnose the 6 y/o M with ADHD. What are next steps that are appropriate in his management?
Educating the parents on behavior management
Referral to therapy for the child
504 plan for school
Medications: Ritalin, Concerta, Adderral, Strattera
You prescribe the 6 y/o M Ritalin XR to be taken once a day. When educating dad on administration, what is an appropriate frequency for this mediction?
Every day before school with breaks on weekends and during school holiday
The 6 y/o M is to start Ritalin XR tomorrow prior to school. When would you like to see him back in the office for follow up?
In 2-4 weeks from initiation of medication. If he is stable at that visit, then change to every 3 months.
At the follow-up appointment at 3 weeks, the 6 y/o M presents with mom. She states that he is doing better in school, but the first few days he was not interested in eating much and coming home most days with a full lunchbox. What will you advise mom on?
Anorexia is a side effect of the stimulant medication. The extended release should diminish this side effect, if it persists can seek alternative medication options.
-Anorexia with weight loss
-Insomnia
-Headaches
-Abdominal pain
-Nervousness, jittery feelings
-Dizziness, HTN, tachycardia
-Skin rashes
-Abnormal LFTs
-Urinary retention
Side effects of ADHD stimulant medications
You are considering starting your patient with newly diagnosed ADHD on a stimulant medication. What diagnostic would you run prior to starting medication?
EKG
Males > Females
Possible genetic connection
Generally presents by age 3
Autism Spectrum Disorder
Symptoms:
-Delayed or not met developmental milestones
-Parental concern for development
-Language and communication deficits
-Lack of eye contact or facial expression
-Lacking social relationship development (with peers or others)
-Tolerance of non-goal directed behaviors
-Rocking, hand-flapping, self-injury, sleeping/eating problems, sensory impairments
Autism Spectrum Disorder
RED FLAGS:
-Failure to meet developmental milestones
-No eye contact
-No single words by 16 months
-No babbling, pointing or gesturing by 12 months
-No spontaneous 2 word phrases by 24 months
-Loss of language or social skills at any age
Autism Spectrum Disorder
When considering a diagnosis of Autism in a child with lack of language skills, you should consider auditory studies for what reason?
Language is developed primarily through sound interaction, if the child cannot hear they may have a delay in language skills
A newly 3 y/o F comes into the office today for her annual well-child appointment. She has been in day care since she was 6 months old, both her parents work full-time, and she has 2 older brothers who developed typically. Mom is concerned that over the past 2 months, the patient has become less social with her peers that she had previously interacted with. Prior to this visit, she has met all her milestones and has had no hearing impairments noted. She can repeat single words, only uses 1-2 word phrases and points to indicate what she would like. When assessing her, you note that she will track you in the room, but does not want to make eye contact when you address her specifically. She has previously not been a shy child. What is a leading differential to consider?
Autism Spectrum Disorder
You have a 3 y/o M with PMH Autism Spectrum Disorder presenting today with his father. Dad wants to get the child into a childcare setting. What is a program you can refer them to?
Birth to 3 through the State of CT
When caring for a child with Autism, who are some interdisciplinary team members that can be helpful?
Neuro
Psychiatry/LCSW
Parental support groups
Care coordinators
Community social worker
Incidence increases with age
Girls > boys after puberty
Low rate of patients who actually seek treatment
RF: FH, female, stressful events, loss, substance use, chronic illness, trauma, abuse, neglect, ADHD, anxiety, cigarette smoking
Depression
Symptoms:
-Irritable mood, sad expression
-Anxiety, somatic complaints
-Unusual behaviors, disinterest in play/normal daily activities they find enjoyable
-Impairment in overall function
Depression
14 y/o F comes in for her annual well-care visit today. As she is an adolescent you speak to her without her parent present at which time she reveals that she does not enjoy going to school, finds it difficult to wake up in the morning, and wants to quit soccer, but her mom won’t let her. When you speak to the parent separately, they state they have noticed a decline in her grades, a lack of interest in social interactions with her peers, and more time napping and watching Netflix alone. What is the next step you would initiate in this patient’s care?
Screen her for depression using Children’s Depression Inventory and a PHQ-9 as well as assess suicidiality
You have a 2 y/o F who presents with dad. She appears very thin and only speaks in 2 word phrases. When speaking, she does stares at the ground, does not look at you or her father. She does not smile or giggle when you attempt to interact with her with a toy. Her dad notes that this is her normal and is concerned with her lack of attachment to her parents when dropping her off at school and her general expressionless face with interactions. What is a lead diagnosis for this child?
Depression
A 4 y/o M comes in with mom after being kicked out of preschool for being aggressive with other students. He has a history of encopresis, well controlled on a stool softener for the past 3 months. Mom notes that at home he seems to be destructive of his toys and is fixated on everyone dying. What is a lead diagnosis for this child?
Depression
-Depressed mood most or nearly everyday
-Marked disinterest in pleasure
-Weight loss >5% in 1 month
-Insomnia or hypersomnia
-Psychomotor agitation or retardation
-Fatigue, loss of energy
-Feelings of worthlessness, excessive guilt
-Poor concentration/indecisiveness
-Recurrent thoughts of death, SI, suicide attempt or plan
Depression criteria per the DSM V
You have a 15 y/o M with a diagnosis of depression being treated with CBT. He states he still has low energy and disinterest in activities he previously enjoyed. He wants to know if there is something he can take to help his mood. You would start with prescribing him…
SSRI
You start your 15 y/o M patient on Celexa once a day. You educate him on the risk for SI and provide him with a crisis hotline number in case these feelings arise and he cannot get in touch with the office. You want to see him back for follow up when?
In 4 weeks. You want to continue ongoing assessment for suicidality at this appointment as the SSRI can improve energy and increase SI and/or attempt
You have a 17 y/o F who comes in for her pre-college physical assessment. She has been on Lexapro for a year for depression. She has been doing well with CBT and denies S/S of depression for over 6 months. She is wondering if she can stop taking her Lexapro prior to leaving for college. You advise:
She with tapering her dose over 6-8 weeks
Girls > boys
Primarily accompanied by depression
Persistent worry or fear for months that impair the person’s age-appropriate functioning
Anxiety
Symptoms:
-Very self-conscious
-Need for reassurance
-Somatic complaints
-Excessive worry or fear
Anxiety
You have a 16 y/o F presenting with feelings of constant worry, racing thoughts, insomnia, and fatigue. She feels that she can’t “turn my brain off” at night from the worry. You screen her with the GAD-7 and she scores for moderate anxiety. In addition to therapy, what medication would you consider?
Zoloft 25 mg PO daily
or any SSRI
You have a 15 y/o M come in for hypersomnia. When you ask him why he is here today, he states “my mom made me come, she thinks I sleep too much, but I’m just a teenager”. When speaking with his mom she notes increased mood swings varying from staying up all night playing video games, spending excessive amounts of money on video games, and having lack of interest in school work followed by hypersomnia and lack of interest in interacting with others or playing video games a week later. The patient’s parents are divorced with little contact with the father due to his lack of desire to seek treatment for bipolar disorder. Mom is concerned the 15 y/o patient has a similar diagnosis. What is your next step?
Reassure mom and refer to psychiatry to further workup of a mood disorder, specifically BP1.
DIG FAST for bipolar:
Distractibility
Insomnia
Grandiosity
Flight of ideas
Activities
Speech (pressured, hypersexual talk)
Toughtlessness
When considering bullying in relation to children today, where does this most commonly take place?
Social media
What is the teen suicide rate?
12-25%
Emotional or behavioral reaction to a stressful event that is maladaptive within 3 months of said event
Adjustment disorder
How would you treat adjustment disorder?
Refer to CBT
Symptoms:
-Uncooperative
-Defiant
-Irritable
-Negative and annoying behaviors toward parents, friends, teachers, and authority figures
Defiant disorder
When treating a patient with defiant disorder, what is the primary treatment?
Counseling, therapy, early intervention is key
RED FLAGS:
-Change or loss of interest in usual activities or appearance
-Withdrawn
-Acting out
-Running away
-Feelings of wanting to die
-Preoccupation with death
-Lack of response to praise
-Giving or throwing away important belongings
-Threatening action/plan
Suicide red flags
Primarily onset in late adolescence-20’s
Male > female
Disturbances of memory or concentration
Changes in emotional response and decreased sense of connectedness
Schizophrenia
Who primarily treats schizophrenia?
Psychiatry
A 17 y/o F comes in today with her mom. Mom has noticed her slapping herself when she needs to focus on school accompanied by nail biting. The patient admits to burning herself with a lighter when no one is around. You are concerned for self-injurious behavior and want to refer the patient to therapy. The patient is concerns about being admitted to the hospital for SI. You screen her for SI and her screen is negative. Mom is concerned about taking her daughter home safely. You educate mom on:
Self-injurous behavior is normally an act of harm with the absence of intent to die. The daughter denies SI and is safe to bring home with assistance from therapy to work on her coping skills
True/False:
Every child, every visit should be screened for child abuse especially with concern
True
You have a patient come in who is noted to have a loss of milestones. What system are you concerned about and where are you referring?
Concern for neurologic development with referral to neurology
5 y/o F presents with multiple light brown spots on her back and abdomen. They appear to you as cafe au lait spots. What is the next step?
Refer to genetics for concern for neurofibromatosis
You have a 15 y/o M presenting with intermittent headaches. He describes them as unilateral, above his L eye, and like someone is squeezing his head when they occur. He takes Tylenol with good effect when they occur. He has noticed that they happen most prior to an exam in a class when he hasn’t been eating to increase his study time. What would you educate him on?
Importance of not skipping meals as this can trigger headaches especially when under stress
Primary or secondary headache concerns:
-Worse in the morning
-Wakens child from sleep
-Vomiting not precipitated by nausea
-Increased pain with straining, sneezing, and/or coughing
-Occipital or neck pain
-Mental, personality, or behavioral changes
-Seizure
-Unsteady/dramatic behavior change
-Fever
-FH of neuro disorder
-PMH: VP shunt, hydrocephaly
Secondary headache concerns
FH migraines
Rapid onset of attack lasting seconds-minutes
Daily attacks in clusters over several days
Acute unsteadiness, nystagmus, N/V, pale appearance, frightened appearance, lethargy, drowsy, normal neuro
BPPV
When completing a BPPV workup, MRI is indicated for what reason?
Rule out a tumor
Symptoms:
-Unilateral or bilateral coordinated motor activity
-Occurs only when observed
-Does not interrupt play
-Pupils normally reactive to light
-Situation specific
-No associated injuries
-No incontinence
-Abrupt recovery with no postictal phase
Pseudoseizures
History:
-PMH: CNS infection, birth trauma
-SH: toxin or drug exposure
-Recent head injury
-FH: seizure
Physical:
-Focal abnormalities/weakness
-HTN
-Systemic disease
-CV disease
-Neurocutaneous disease
-Signs of head trauma
-Transillumination of the skull
Seizure disorder presentation
Diagnostics in seizure disorders are helpful for:
Guiding management plan
A 6 y/o M comes to the office today for his annual well-child visit. He has a witnessed seizure 2 months prior and is being followed by pediatric neurology for his management. Summer is coming up and the patient is excited for summer camp. He really wants to swim at camp this summer and mom is concerned about the safety. In conjunction with his neurologist, what is the best action plan for this child?
Neurology is primary for the stability of his disorder on medications
The child should wear a medical alert bracelet at all times
If cleared by neurology, he can swim at camp with a 1:1 supervision in the water at all times
You have a 5 y/o F coming in for her pre-kindergarten visit. She is due for her DTap at this visit. She was diagnosed with epilepsy at 4 years old and has been stable on her regimen. You have already discussed her plan with her neurologist. Can you administer the DTap at this visit?
Yes, DTap is safe as long as the epilepsy is stable and verified with neurology
Most common seizure type in children
Brief, generalized
Concurrent with an illness
Febrile seizures
The mother of a 13 month old calls you saying she went to the ED yesterday with the child after the child was thrashing and unresponsive. The child felt very warm at the time and was noted to have a temperature of 104F when EMS arrived. In the ED they treated the fever and underlying illness. She is concerned if the child needs a neurology workup for seizures. There is not FH of seizure disorder. This is the first episode for this child. What would you recommend?
Counsel and educate mom on febrile seizures
No need for referral to neurology at this time
You’re assessing a 1 month old. When picked up, the infant droops over your hand and is almost “floppy” appearing. Who would you refer this child to?
Genetics
Sudden, acute onset unilateral paralysis/weakening of facial nerve without sensory loss
Recent viral infection
Bells Palsy
Caudal end of the spinal cord fixed at or below L2 with noted neurologic deterioration is:
Tethered cord
Normally associated with spina bifida
