Lecture 10: Pediatric Psychiatry Flashcards
Goals of psychiatric interview-overall (3)
- Come to a diagnostic formulation
- Provide a therapeutic intervention
- Create a foundation for treatment
Parental Interview Goal (3)
- Form an alliance
- Obtain a formal hx
- Obtain info about
- relationships
- family dynamics
- values
- communication
Infant Interview Goals (4)
- Determine causes of disturbances
- in regulation
- social
- psychophysiologic
- developmental delays
Child Interview Goals (6)
- How the child feels
- What the child thinks the purpose is
- Correct misunderstandings
- Assess development
- Gauge coping skills
- Establish alliance
Adolescent Interview Goals (3)
- Establish possible diagnosis
- build rapport
- build a foundation for treatment
Family Interview Goals (5)
- Gather comprehensive history
- Observe and assess family interactions
- Formulate family diagnosis and treatment plan
- Educate and motivate for treatment
- Build therapeutic relationship
Interviewing Parents (2)
- intake questionnaires and checklists
2. Work through the domains of a psychiatric evaluation
Interviewing Infants (3)
- interview the parents
- observe parent-child interactions
- standardized testing (developmental level scales)
Interviewing Children (4)
- Interview structure depends on the child
- Unstructured vs. semi-structured vs. structured
- Help them relax; toys, no white coats, no notebooks
- little ones are concrete-ask pointed questions
Interviewing Adolescents (5)
- listen
- don’t be too formal
- start with easier topics
- ask about SI
- discuss confidentiality
Family Interview (2)
- Identify problems
2. Observe family interactions
Mental Status Exam (2)
- organized observations and assessments of behavior during the assessment
- helpful in refining diagnosis and knowing where to look further
**OBJECTIVE
Treatment Planning (5)
- safety first
- identify goals of treatment
- look at all factors
- treat -> monitor -> revise
- consider risks and benefits
Intellectual Disability Dx
- not a single d/o
- Onset before age 18
- Impairment in intellectual and adaptive functioning
- varying levels of severity
Mild MR
IQ 50-55 to 70
*verbal skills lack below 50 typical
Moderate MR
IQ 35-40 to 50-55
*verbal skills lack below 50 typical
Severe MR
IQ 20-25 to 35-40
Profound MR
IQ 20-25
Intellectual Disability Epidemiology (5)
- 0.7%-1% prevalence
- 2/3 of cases are mild
- increased rx for comorbidities
- multitude of cases: prenatal/perinatal/postnatal
- can be genetic or external
Diagnostic Testing for Intellectual Disability (7)
- psychological testing**
- genetic testing
- metabolic screening
- EEG
- hearing acuity evaluation
- ophthalmologic assessment
- neuroimagining
DDX for intellectual disability (5)
- dementia
- PDD -austism
- learning d/o
- communication d/o
- other mental d/o
Treatment intellectual disability (5)
- treatment and education based on strengths and weaknesses
- behavioral management programs
- early intervention services
- psychopharmacologic bass on specific symptoms
- other: OT, PT, ortho, GI, etc.
Special consideration intellectual disability (5)
When using medication in this population
- rule out all other causes for behaviors
- use least intrusive medication at the lowest effective dose
- avoid poly pharmacy if possible
- monitor closely
- goal is maximizing quality go life not eliminating challenging behaviors
Learning D/O diagnosis
- Significant difficulties in learning and using skills such as listening, speaking, writing, reasoning or math
- achievement well below average on standardized testing and interferes with achievement or daily activities
DSM 3 types learning d/o
- reading d/o
- math d/o
- written expression d/p
Epidemology learning d/o (2)
- estimated 2%-8% of school aged children
2. can be intrinsic or environmentally influenced
Dx and Tx learning d/o (4)
- Psych testing (WISC-III)
- Remedial Approach- improve specific skills
- Compensatory approach- work about deficit
- interventions for related social/emotional issues
Motor D/o Dx (4)
- performance in daily motor functioning is far below expected
- disturbance interferes with academic achievement or ADLs
- Not due to general medical condition or PDD
- if MR is present, motor difficulties are more than expected
Motor Disorders (6)
- clumsiness
- Adventitious movements
- Dyspraxia
- material-specific dyspraxia
- neurologic soft signs
- pathologic handedness
Clumsiness
Motor D/O
inefficiency in performance of fine motor movements
Adventitious Movements
Motor D/O
synkinesis, chorea, tremor, tics
Dyspraxia
Motor D/O
inability to learn or perform serial voluntary movements to complete skilled acts
Material-Specific Dyspraxia
Motor D/O
motor execution below expected age with regard to writing (dysgraphia), drawing (constructional dyspraxia), or speech (verbal dyspraxia)
Neurologic Soft Signs
Motor D/O
non normative performance on motor or sensory neurologic tests in the absence of localizable neurologic disease or defect
Pathologic Handedness
Motor d/o
left-handedness assoc with left-hemispheric defect and paresis of the right hand
Epidemiology Motor d/o (3)
- 6% school aged children
- genetic cause, possibly “minimal brain damage”
- typically improved throughout development
Diagnostic Testing (5)
- development hx (questions about motor performance)
- neuro exam
- specific assessment procedures based on sx
- psych testing
- neuroimaging
DDX Motor d/o (4)
- neuroleptic/anticonvulsant toxicity
- neuromuscular d/o
- upper motor neuron d/o
- other d/o involving motor issues
Motor d/o tx
- pysiotherapy and occupational therapy for remediation of motor handicaps
Communication D/O
- must be severe enough to interfere with patient’s
- school
- occupational achievement
- social communication - must exceed expectations for age/IQ/Dialect
Communication D/o types (4)
- expressive language d/o
- mixed expressive-receptive language d/o
- phonological d/o
- stuttering
Signs/Sx Expressive Language D/O (4)
Communication D/O
- limited vocabulary
- errors in grammar
- difficulties with word recall
- difficulties with sentence production
Signs/Sx Mixed Expressive-Receptive Language D/O
Communication D/O
- same as expressive language d/o
- difficulties processing or understanding spoken words/sentences
Phonological D/O signs/symptoms
Communication D/O
- developmentally inappropriate difficulties with sounds (production, use, organization)
Suttering D/O signs and sx
Communication D/O
- disturbance in normal fluency and patterning of speech
Epidemiology Communication d/o (5)
- 2-7%
- elevated rate psych comorbidity
- occurs more frequently in families with hx of language d/o
- 4x more likely in boys than girls
- genetic or acquired
DDX Communication D/O (3)
- autism
- PDD
- ADHD
Diagnosis Communication D/O
- psych testing
- audiological testing
- neuroimaging if neuro exam abnormal
Tx Communication D/o
Therapeutic services
Autism Signs/Sx (6)
- Wide range sx and severity
- Difficulties with social interactions
- abnormal eye contact
- delays/abnormalities in language
- lack of interest ing environment
- repetitive behaviors/ difficulties with change in routine
Autism Dx (4)
- qualitative impairment in social interactions (at least 2)
- Qualitative impairment on communication (at least 1)
- Restricted, repetitive, and stereotyped patterns of behavior, interests, and acitivites (at least 1)
- 6 total items from diagnostic list
Epidemiology Autism (5)
- 4.5-9 per 10,000
- boys 3-4x more likely than girls
- high rates seizure d/o, persistence of primitive reflexes, “soft” neurological signs
- 2%-10% in siblings
- work being done on genetic factors, obstetrical risk, environmental factors
Diagnostic testing autism (5)
- psych testing
- strengths in nonverbal tasks, but deficiencient in verbal cognitive abilities - most function in MR range
- savant skils
- EEG abnormalities may be seen (not diagnostic)
DDX Autism (4)
- other developmental d.o including PDD
- sensory impairment
- MR
- Language d/o
Treatment Autism (6)
- Education and behavioral interventions
- antipsychotics
- SSRIs
- mood stabilizers
- psychodynamic therapy
- 20% + able to become independently functioning adults
Pervasive Developmental D/O
- Aspbergers
- Childhood Disintegrative D/O
- Rett D/o
- Pervasive Developmental D/O NOS: Autism Spectrum
Asperger’s
PDD
Social disability with good verbal skills
childhood disintegrative d/o
PDD
rare condition in which a condition life autism develops after a time of normal development
Rett D/O
PDD
Neurodegenerative D/O
Pervasive Developmental D/O NOS
PDD
Autism Spectrum D/O
Attention Deficit D/O Signs and sx (6)
- inattentive
- distractible
- impulsive
- hyperactive
- poor organization
- daydreaming
- frequently changing activities
- poor time management ‘
- low frustration tolerance
ADHD Dx (5)
- 6+ sx of inattention OR
- 6 + or more sx of hyperactivity
- some impairment of these symptoms in 2+ settings
- Evidence of significant impairment in social/academic/occupational functioning
- sx are not only during the course of another d/o
Epidemiology ADHD (6)
- Most common emotional/cognitive/bx d/o treatment in youth
- 4-7% children
- combined= 50-70%
- inattentive= 20-30%
- hyperactive/impulsive= <15% - Girls more commonly have inattentive type
- biologic adversity rx
- psychosocial adversity rx
- highly genetic, 77%
Diagnostic Testing ADHD
- Diagnosis made by careful hx
- rating scales for screening
- psych testing (not necessary but can be beneficial)
DDX AHDH (6)
- ODD and conduct d/o
- mood d/o (mania)
- anxiety d/o
- learning disability
- Tics
- substance use d/o
Tx ADHD (6)
- Psychostimulants
- Strattera (SNRI)
- Antidepressants (TCAs, Wellbutrin)
- Alpha agnoists
- Modafinil
- psychotherapeutic interventions
Opposotional Defiant D/O
Signs/Sx (10)
- Oppositional
- Tests Limits
- disruptive behaviors
- moddy
- irritable
- often in conflict
- argumentative
- angry
- easily loses temper
- spiteful
ODD Dx (5)
- Pattern of negative, hostile, and defiant d/o
- lasts at least 6 month
- disturbances causes impairment in social/ academic/occupational functioning
- symptoms not exclusive to another psych d/o
- criteria not met for conduct d/o
Epidemiology ODD (6)
- 5.7-9.9%
- average onset 6 years
- 4:1 M:F
- low heritability
- increased rx with infants with disorganized attachments, highly stressed families
- related to failure to provide adequate praise, attention, and consistent limits
DDX ODD (6)
- normal developmental testing
- ADHD
- Conduct D/O
- Pre-morbid schisophrenia
- oppositionality with MR
- parental psychopathology
Dx and treatment ODD (4)
- Psych testing (behavioral check list)
- under 12: treatment through parents
- adolescents: family therapy approach
- Problem solving communication training (PSCT)
Conduct Disorder Diagnosis (3)
- Repetitive violation of social norms/rules
- Behaviors cause impairment in social, academic or occupational functioning
3. Disruptive or dangerous behaviors 3+ -Agression to people or animals -property destruction -deceitfulness of theft -seroius violations of rules
Epidemiology Conduct Disorder
- 0.9-8.7%
- Multiple etiologic theories
- genetic
- physiological
- acquired
DDX Conduct D/O
- Mania
- Dysthymia/ MDD
- Likely to coexist with
- ODD
- ADHD
- Substance use
- Learning d/o
- Depression
- PTSD
- Anxiety
Dx Conduct D/O (2)
- comprehensive biopsychosocial evaluation
2. psych testing can provide insight
Tx of Conduct D/O (3)
- psychosocial intervention
- ecological intervention
- biological intervention s
Pharmacological tx conduct d/o
- methylphenidate
- Depakote
- Lithim
Methyphenidate Tx in conduct d/o
reduce defiance, oppositionality, aggression
Depakote tx in conduct d/o
reduce hyperarousal, anger, agression
Lithium tx in conduct d/o
reduce agression
Prognosis ODD
ODD -> Conduct D/O -> antisocial PD
Additional Pathways:
- substance use
- covert/nonaggressive
- aggressive/versatile
- authority conflict
