Intro to Childhood Psychiatric Disorders, Part I -Ryst Flashcards
1
Q
How do you interview a child?
A
interview the child together and separately from the family.
2
Q
What should you ask in a child assessment?
A
- Behavioral difficulties
- Functional Impairments
- Subjective Distress
- Stressors and Environmental Factors
- Adverse Impact on Development
3
Q
What are the four domains of functioning that you must assess in a child?
A
Home-family
school-education
peers-friends
extracurricular activities-play
4
Q
Must check a kids physical and medical history …such as?
A
height/weight, medicall illnesses, coordination, motor function, milestones, sexual development etc.
5
Q
WHat are the 6 histories you must get from a child?
A
School History Emotional Development and Temperament Substance use Peer Relations Family Relations Trauma
6
Q
In the family interview, what do you want to look for?
A
- parental attitudes toward child
- discipline practices
- parental attachment
- “goodness of fit”
- socio-cultural factors
- communication styles
7
Q
In the child interview what do you need to do to connect with the child and what questions do you need answered?
A
- require flexibility and creativity (must use techniques appropriate to child’s deveopmental level)
- use interactive play, projective techniques or direct discussion
- perform developmental mental status
- ask about child abuse
- establish alliance with the child
8
Q
Once you are finished with the child assessment, what do you say and do?
A
- consider need for referral
- come up with diagnosis
- communicate findings and recommendations
9
Q
What is the goal of child treatment, whats the best way tot go about it?
A
- promote healthy development and max the child’s adjustment in the four domains (home, friends, school, play)
- multi-modal treatment
10
Q
What are some of the tools to utilize psychotherapy?
A
Play therapy, interpersonal psychotherapy (effective for adolescents), cognitive-behavioral therapy (can use at age 7), parent guidance therapy, family therapy.
11
Q
Tell me about kids and meds?-
A
- kids metaboize drugs different, therapy and adverse effects differ in kids,
- use with caution, can help children
- prescribe “off label” meds
12
Q
Whats up with tricyclic antidepressants and kids?
A
they dont work in kids
13
Q
Untreated mental illness is toxic and can disrupt development and result in long term consequences, this is why you should use (Blank). As long as the benefits outweight the risks
A
meds
14
Q
How do you advocate for a child?
A
- School intervention
- Psychoeducation
- Referral to community resources: support groups, respite, learning aides, educational advocates, social services
- Comprehensive treatment plans
15
Q
What is this:
“A recurrent pattern of negativistic, hostile and defiant behavior.”
Must have at least four of the following for at least six months:
Often loses temper
Often argues with adults.
Often actively defies or refuses to comply with adults’ requests or rules.
Often deliberately annoys people.
Often blames others for mistakes or misbehavior.
Often touch and easily annoyed.
Often angry and resentful
Often spiteful and vindictive
A
Oppositional Defiant Disorder
16
Q
What is this: Violation of the rights of others and age-appropriate social norms. Must have at least three symptoms in the last 12 months, with at least one symptom in the last 6 months. Bullying or threatening others. Fighting Using a weapon that can cause serious physical harm. Physically cruel to animals. Physically cruel to people. Stealing while confronting a victim. Forcing someone into sexual activity. Fire setting. Destroying property. Breaking into a house, building or car. Frequent lying or “conning.” Stealing without confronting a victim. Staying out late despite parental prohibitions. Running away from home. Being truant from school.
A
Conduct disoder
17
Q
What is a kid like that has a CD diagnosis with limited prosocial emotionals?
A
have CD and have a lack of empathy, guilt, concern and have a shallow affect. Have great amount of aggression and are likely to develop antisocial personality disorder. Tend to have problems earlier (9-10).
18
Q
ODD has a prevalence ranging from (blank); it’s twice as common in (blank).
A
2-16%
males as females
19
Q
(blank) problems are more common in males (outward behaviors)
(blank) problems are more common in females (inward coflict)
A
external
internal
20
Q
Conduct Disorder prevalence = (blank) for males < 18 years and (blank) for females < 18 years.
A
9%
2%
21
Q
Males with early-onset CD are much more likely to show (blank) symptoms.
A
aggressive
22
Q
Onset of CD is particularly early in (blank) boys. CD boys with (blank) have a worse outcome than CD boys without it.
A
ADHD
ADHD
23
Q
Early onset of CD is often preceded and predicted by persistent (blank) symptoms.
A
ODD
24
Q
T or F
A significant subset of ODD children go on to develop Conduct Disorder; however, not all children with ODD develop CD.
A
T
25
If a child has ODD, what symptoms are most associated with likelihood of gaining CD?
- cruelty to people and weapon use
- physical fighting
- proactive aggression (worse than reactive aggression)
- overt disruptive behavior (worse than covert disruptive behavior)
26
Symptoms that are not typical of (blank and blank) are symptoms associated with a longer course of CD... for example...?
age and gender
- In younger kids, syx of cruelty, running away and breaking into a building most predictive of CD.
- For girls, fighting and cruel behavior are atypical symptoms and most predictive of CD.
27
The presence of early Anti-Social Personality or psychopathy-related symptoms such as (blank, blank and blank) may predict the eventual development of Anti-Social Personality Disorder.
(egocentricity, callousness, manipulativeness)
28
WHat are frequent psychiatric comorbidities associated with CD?
```
ADHD
Anxiety
Mood disorders
Substance abuse
Learning disabilities
```
29
Mood disorders and CD increases risk of (blank and blank)
Substance abuse and suicide
30
Substance abuse and conduct disordesr have a (blank) relationship, each exacerbates the other
reciprocal
31
Conduct disordered youth are more likely in adulthood to.....?
- have great psychiatric impairment
- have high rates of criminal behavior
- less likely to be employed
- high rates of school drop out
- high rates of failed marriages
- more likely isolated
- higher mortality rates
32
How do you treat disruptive behavior disorders?
- mutimodal approach and involve parents
- parent-direct component, social-cognitive skills training, academic skills training, proactive classroom management and teacher training
33
Are there any FDA-approved drugs to treat dirsruptive behavior disorders?
no
34
What drugs can you use for disruptive behavior disorders?
-mood stabilizers, typical and atypical antipsychotics, Clonidine and the stimulants may help to decrease aggression, reduce emotional reactivity and moderate levels of emotional arousal.
35
How do you treat younger children with ODD?
parent management training
| PCIT (parent-child interaction training)
36
What is this:
Trains parents to interact with child in a way that promotes pro-social behavior. Focuses on antecedents and reinforcement. Combination of parent and child training is superior to working with parent alone.
parent management training
37
What is this:
.
First phase: Parents trained in nondirective play skills to alter quality of parent-child interactions.
Second phase: Parents taught to give clear instructions, praise for compliance, time-out for noncompliance.
PCIT (parent-child interaction training)
38
WHat is this:
Addresses risks at the individual, family, peer, school and neighborhood level. Treatment is intensive and addresses therapeutic barriers such as parental substance abuse, parental psychopathology, marital conflict, associations with delinquent peers, poor school performance and deficient problem-solving or perspective-taking skills.
MST (multisystemic therapy)
| ***very expensive so people dont really do this*****
39
In the past, childhood mood disorders have been misunderstood diagnosed due to ....?
- childrens inability to express emotion verbally
- tendency of adults to notice only obvious, external symptoms
- bipolar disorder difficult to diagnose in children due to developmentally different presentation in children as well as overlap with ADHD
40
For depression, the diagnostic criteria is the same is kids as it is in adults except for....?
yes, its mostly the same except for a few things
For children and adolescents-> can have irritable mood instead of depressed mood
-> failure to make expected weight gains
41
For dysthmic disoder, the diagnostic criteria is the same in kids as it is in adults except for,,,?
mood can be irritable rather than depressed, and duration must be at least one year (not two)
42
WHat is this:
Somatic complaints, psychomotor agitation, mood-congruent hallucinations more prevalent.
Can also manifest as separation anxiety, phobias, and behavioral problems.
Look for deviations from developmental trajectory: school failure, withdrawal from peers, lack of interest in prior activities.
depression in children
43
What is this:
Can present as antisocial behavior, substance use, restlessness, grouchiness, aggression, withdrawal, school or family problems, feelings of wanting to leave home, feelings of not being understood, loved or approved.
depression in adolescents
44
What does juvenile bipolar disorder present as?
- more frequent "mixed" states
- "rapid cycling"
- chronic and continuous rather than acute and episodic
- seldom ass. w/ euphoria -usually prominent irritability w/ affective storms, prolonged aggressive temper outbursts, emotional lability.
- in older children (greater than 9), euphoria, elation and grandiosity more common
45
What are associated symptoms with juvenile bipolar disorder?
- Decreased need for sleep
- Rapid speech, talkativeness
- Distractibility, racing thoughts, tangentiality
- Hypersexuality
- Increased goal-directed activity
- Impulsivity
- Abnormal thought content, paranoia
46
What besides bipolar symptoms do you need to diagnose BP1 or BP2 mania or hypomania states?
increase energy/activity
47
In children, if the individuals with subthreshold mixed states are not meeting full crtieria for depression and mania then what do you call them?
bipolar with mixed features
48
How do you add anxiety to a bipolar disorder?
bipolar with anxious distress
49
(blank) is a diagnosis for children with extreme behavioral dyscontrol but persistent, rather than episodic, irritability and reduces the likelihood of such children being inappropriately prescribed antipsychotic medication.
Disruptive Mood Dysregulation Disorder (DMDD)
50
What is the prognosis of childhood mood disorders?
poor
51
Typical depressive episodes in children have a duration of (blank) months (up to 10% last 2 years)
3-9
52
What is the recurrence rate of depression in children?
70% in 5 years
53
(blank) percent of children develop bipolar disorder within 5 years of depression and have a high likelihood of having (blank) in adulthood.
20-40%
| recurrent depressive episodes
54
If you have prepubertal major depression, what are some adverse outcomes?
Impairment in school, family, friendships.
Increased risk of suicidal behaviors and suicide.
Tobacco and substance abuse.
Early parenthood.
55
Juvenile Bipolar disorder has what kind of prognosis?
poor
56
With JBD, there is a high occurence (59%) of (Blank)
psychosis
57
How long is JBD recovery? And what are the rates of recovery? whats the rate of relapse?
28. 6 weeks
37. 1% at 1 year, 65.2% at 2 years
55. 2% relapse before second year of follow-up
58
To treat major depression, (blank and blank) have been shown to have equivalent efficacy to anti-depressant medications.
CBT and IPT
59
What is this:
Challenging distorted thoughts of negative view of self, others and future.
Behavioral activation.
Mood monitoring.
Is this effective?
CBT (cognitive-behavioral therapy)
64% remission rate in CBT vs. 39% for supportive therapy after 12-16 week treatment course.
60
What is this:
Focus on interpersonal conflicts, grief, role disputes, role transitions, interpersonal deficits.
Is this effective?
IPT (interpersonal therapy)
75% response rate IPT vs. 46% control group
61
What antidepressent meds can you use with kids?
SSRIs (40-70% response rate)
-watch for mania and suicide
Atypical anti-depressents (bupropion, mirtazapine)
62
What is the most effective way to treat children with depression?
meds and psychosocial therapy simultaneously
63
What is psychosocial augmentation?
- education
- mood hygiene
- school interventions
- support groups
- CBT for anxiety and depression
64
almost all anxiety disorders are (blank)
co-morbid
65
What are the common clinical characteristics of pediatric anxiety disorders?
- Developmentally inappropriate, unrealistic and excessive anxiety.
- Subjective distress.
- Cognitive– worry, catastrophizing
- Physiological—heart, respirations and GI/GU
- Anticipatory anxiety
- AVOIDANCE
- Adult Accomodation
- Triggered by exposure
- Wax and wane
- Highly comorbid
66
Is separate anxiety a normal part of the developmental process at 18 months of age?
yes
67
What should you look for in a pediatric anxiety patient?
- physical complaints (headaches, stomachaces, dramatic pain presentations)
- problems with sleep
- eating probems
- avoidance of outside and interpersonal activities
- excessive need for reassurance
- inattention and poor performance at school
68
THe DSM has grouped anxiety disorders into four distince chapters, what are they?
- fear-based anxiety
- disorders of obsession or compulsion
- trauma-related
- dissociative disorders
69
In generalized anxiety disorder, the criteria is the same in children as it is in adults except for.?
you only need 1/6 symptoms
70
Who gets generalized anxiety disorders most?
| What is the most common comorbidity associated with this?
girls=boys in childhoos, but girls> boys in adolescent
(3-12% prevalence)
major depression
71
What is this:
Inappropriate, excessive anxiety re: separation from home or attachment figures.
Need 3 or more:
Distress when separation from home or attachment figures occurs or is anticipated.
Worry about losing, or possible harm befalling attachment figures.
Worry that an untoward event will lead to separation from attachment figure.
Reluctance or refusal to go to school or elsewhere due to separation fear.
Fearful or reluctant to be alone at home or without significant adults in other settings.
Reluctance to got to sleep without being near an attachment figure or sleep away from home.
Repeated nightmares about separation.
Repeated physical complaints when separation occurs or is anticipated
separation anxiety disorder
72
How long do you need to show symptoms of separation anxiety to get the diagnosis?
minimum of 4 weeks
73
who gets seperation anxiety more? What causes it?
What is it commonly co-morbid with?
What is the onset like?
girls> boys
Genetics, modeling and parent-child relationship play a role.
Comorbidity with MDD, GAD, ADHD and school refusal
acute or insidious
74
Symptoms of separation anxiety can be induced by what medications?
Haldol, inderal, pimozide
75
What is this:
Consistent failure to speak in specific social situations despite speaking in other situations.
Disturbance interferes with educational achievement or social communication.
Failure to speak is not due to language problems.
Is not better accounted for by a Communication Disorder, and doesn’t occur only during a Pervasive Developmental Disorder or Psychotic Disorder.
How long does this disorder have to go on for to get the diagnosis?
selective mutism
Duration at least 1 month
76
What is the prevalence of selective mutism?
What is it assocaited with?
What is it often diagnosed with?
Very rare, prevalence <1%
excessive shyness, fear of social embarrassment, social isolation and withdrawal, clinging, temper tantrums or controlling and oppositional behavior.
Another anxiety disorder (such as social phobia)
77
The diagnostic criteria of specific phobia in children is the same as in adults except for...?
(blank) pecent have another anxiety disorder.
Children’s anxiety response may be expressed as crying, tantrums, freezing and clinging.
Children don’t have to realize that fear is excessive or unreasonable.
Duration at least 6 months.
70%
78
With juvenile OCD, it has the same DSM criteria as for adults, except children don’t have to (blank). What is the prevalence in kids?
realize that the obsessions or compulsions are excessive and unreasonable.
1-4%
79
Talking about OCD:
| In the prepubertal population, it is common to see (blank) without (blank)
compulsions without obsessions
80
Children do exhibit transient age-appropriate OC behaviors that wax and wane with normal development, eg bedtime rituals, superstitions, concerns about sameness. What will make these abnormal?
It’s abnormal if it persists and causes excessive distress or impairment
81
WHat is PANDAS? Why is it important?
Pediatric Autoimmune Neuropsychiatric Disorders Associated with Strep
-can be confused with OCD
82
With social anxiety disorder/social phobia, it has the same DSM criteria as for adults, except children...?
must show evidence of capacity for age-appropriate relatioships w/ familiar people, and the symptoms must occur w/ peers as well as adults
- children can express anxiety as crying, trantrum, freezing, or shrinking
- children dont have to realize that its unreasonable
- duration of at least 6 months
83
What is the prevalence of social anxiety disorder/social phobia?
What age do you typically get it?
Is it usually chronic or acute?
What is it comorbid with?
5-15%
11-12 years old
chronic (if untreated can persist into adulthood)
anxiety disorders, ADHD, depression and substance abuse
84
What is a panic disorder like in children? Is it common in adolescent or children?
it is the same as in adults
| adolescents; rare in children
85
If you have a panic disorder present prepubertally, what does this indicate?
may signal greater severity
86
Panic attacks often begin at onset of or during episodes of (blank) or (blank)
depression
| separation anxiety
87
What are the four components of posttraumatic stress disorder?
- intrusion symptoms
- avoidance symptoms
- negative alterations in mood and cognition
- alterations in arousal and reactivity
88
Numbing has now been expanded to include what?
negative mood and cognitive symptoms
89
Is there separate criteria for PTSD in young children (6 years and younger)?
yes
90
What is DSED (disinhibited social engagement disorder)?
similiar to ADHD and disruptive behavior disorders an occurs in children with both insecure and more secure attachments
91
What is RAD (reactive attachment disorder)?
Similiar to depression and other internalizing disorders but reflects poorly formed or asbent attachments to others
92
How do you treat pediatric anxiety disorders?
Meds: SSRIs are first line tx for Generalized Anxiety Disorder, Separation Anxiety Disorder, social phobia, panic disorder
Psychosocial therapies: CBT, coping cat
93
What does this:
| Recognizing anxious feelings and thoughts, identifying somatic reactions and developing a plan to cope.
The coping cat
94
How do you treat OCD?
- clomipramine and SSRIs
- exposure response prevention (ERP)
- combined treatment is best
95
How do you treat specific phobias?
- graduated, in vivo exposure with contingency management
| - medication to effective unless comorbidity
96
How do you treat specific phobia?
- graduated, in-vivo exposure with contingency management
| - medication not effective unless comorbidity
97
How do you treat specific panic disorder?
-use adult treatments
98
How do you treat social phobia?
CBT: psychoeducation, exposure, skill building, homework
99
How do you treat selective mutism?
Prozac
100
How do you diagnose early onset schizophrenia in children?
| Is it prevalent?
has same diagnostic criteria as adults
| no, really rare in ages below 15 and even more rare pre-pubertal
101
It is difficult to diagnose psychosis in children due to...?
- Overactive imaginations
- Developmental delays
- Language problems
- Postraumatic phenomena
- Misperceptions of questions asked.
102
A child with (blank) requires a full medical work-up, including investigation of endocrinologic, metabolic, neurologic, infectious and toxic causes.
true new-onset psychosis
103
What is the first line drug for early onset schizophrenia?
second line?
For treatment resistant cases?
atypical antipsychotics
typical antipsychotics
Clozapine and ECT
104
What are the psychosocial interventions associated with early onset schizophrenia?
- Psychoeducation
- Behaviorally-based family therapy (Goldstein and Miklowitz)
- Cognitive-behavioral therapy (Rector and Beck)
- Weight management
- SPED/vocational training
105
Are sleep problems common or rare in kids and adolescents?
20-30%
106
What are some assessment tools for pediatric sleep disorders?
- sleep diaries
- bedtime routines and sleep associations
- unusual behaviors in sleep
- sleep-related breathing problems
- daytime alertness
- conducting physical exam looking for obstructive sleep apnea risk factors (craniofacial anomalies, tonsiller size, septal deviation of nose)
107
Sleep disorders affect (blank) % of 6-12 month olds and (blank) % of 1-3 year olds.
25-50
| 15-20
108
What are the signs/symptoms of sleep onset association disorder?
Calls for parents after night wakings
Sleep initiation requires parental involvement
Inappropriate sleep associations (falls asleep in parents’ arms).
109
How do you treat sleep onset association disorder?
Behavioral interventions
- put to bed awake but sleepy
- new routines
110
What are parasomnias?
disorders of arousal, child looks like she is awake, but EG shows that she is asleep
111
What are sleep terros?
Occurs during first third of the night; autonomic arousal with tachycardia, tachypnea, sweating, inconsolable screaming; amnesia for the event.
112
Who gets sleep terrors? What is the prevalence? when does it occur? How do you treat it?
- toddlers and school-age children
- 3% prevalence
-reassurance of parents, avoid sleep deprivation; benzodiazepines for severe cases
113
What is sleep walking and when does it occur?
| What age does it occur in and what is the prevalence?
Occur 1-2 hours after sleep onset; walk for a few mins. up to ½ hour; confusion; incoherence; difficult to awaken; amnesia for the event.
4 to 8 year olds
15-40% have one episode; 3-4% weekly/monthly episodes
114
How do you treat parasomnias?
reassurance, safety measures; benzo's in severe cases
115
(blank) occurs in 1-2% of children. It is characterized by habitual snoring, noisy breathing; pauses in breathing; nocturnal sweating; mouth breathing
Obstructive sleep apnea
116
How do you diagnose OSA?
sleep study
117
What is the treatment for OSA?
Adenotonsillectomy (if appropriate) and CPAP
118
What is delayed sleep phase syndrome?
delay in sleep onset by 3-4 hours, then difficulty waking up in the AM causing sleep deprivation, impaired academic functioning, conflict with parents.
119
Who is delayed sleep phase syndrome most common in?
| Why?
adolescents
| due to normal delay in circadian rhythms
120
What is the treatment for delayed sleep phase syndrome?
light therapy, behavioral interventions, possibly melatonin
121
WHen does narcolepsy start and what is the prevalence?
| What are the symptoms?
adolescence
-0.05%
cataplexy, hypnogogic hallucinations, sleep paralysis, sleep attacks
122
How do you diagnose narcolepsy?
polysomnogram and multiple latency test, hypocretin deficiency in CSF
123
What is the treatment for narcolepsy?
Modafinil or stimulants for daytime sleepiness
SSRIs or TCAs for cataplexy; scheduled naps
124
What is good sleep hygiene?
- schedule bedtime and wake-up
- synchronize the sleep-wake rhythm w/ the circadian clock using light in AM at schedule wake time
- exercise during the day
- hot bath few hours before bed
- avoid daytime naps, excessive temp, noise, light, alcohol and caffeine
- time in bed: only for sleep
125
What is encopresis?
repeated passage of feces into inappropriate places whether involuntary or intentional
126
How long do you have to be having encopresis for it to be diagnosed?
What age group usually gets this?
at least one event per month for at least three months
| -at least four year olds (4 year old developmental level)
127
Is encopresis due exclusiely to a substance or general medical condtion?
No, except through a mechanism involving constipation.
- With constipation and overflow incontinence
- Without constipation and overflow incontinence.
128
What is the prevalence of encopresis?
1% of 5 year olds
129
What are the causes of encopresis?
- Precipitating psychosocial stressors
- Expression of anger, ODD
- Initiation of a cycle of chronic constipation (anal fissure, struggle over toilet training, phobic avoidance of toilet), leading to fecal retention, weakening of anal sphincter and decreased sensation in the rectum.
- Psychodynamic explanations: the mother-child relationship and maternal ambivalence regarding child’s autonomy.
130
What is the treatment for encopresis?
- medical management of constipation
- 10 minus toilet sittings 20 minutes after meals
- behavioral incentive programs
- aversive consequences for soiling accidents
- psychotherapy/family therapy
131
What is this:
| Repeated voiding of urine into bed or clothes (whether involuntary or intentional).
Enuresis
132
How often does a child have to wet the bed to get the diagnosis of enuresis? How old do you have to be to get the diagnosis enuresis?
Either 2x/week for 3 consecutive months, or clinical distress or impairment
-age of at least five years chronologically or developmentally
133
Can you get enuresis from a substance or medical condition?
no
134
What are the subsets of enuresis?
- nocturnal only
- diurnal only
- nocturnal and diurnal
135
What is the prevalence of enuresis?
15% of five-year-olds, with a decrease of about 15% per year afterwards
136
What should you rule out before you make the diagnosis of enuresis?
```
diabetes mellitus
diabetes insipidus
psychogenic polydipsia
UTI
seizure disorders
renal insufficiency
neurogenic bladder conditions, neuroleptic-induced enuresis, urinary tract anomalies.
```
137
What is the etiology of enuresis?
- Maturational delay
- Genetic disorder
- Manifestation of stress
138
How do you treat enuresis?
- usually self-limited
- chart symptoms, positive reinforcement of dry periods, nighttime fluid restriction and encouragment of nighttime urination
- enuresis alarm (Bell and pad)
- DDAVP, Imipramine
139
What is this:
| children with significantly restricted eating patterns or nutrional problems
avoidant/restrictive food intake disorder
140
What is the deadliest psych disorder?
anorexia nervosa
141
T or F
| in grades 3-6 almost 50 percent wanted to be thinner and 40 percent had tried to lose weight
T
142
What are the covert signs of eating disorders?
bulky oversized lothing, obsession with food/cooking, frequent trips to the bathroom,
143
What are the high risk groups for ED?
runner, skaters, gymnasts, models, dancers, wrestlers, cystic fibrosis, diabetes, depression, sexual abuse
