Mental/Emotional Health + Trauma/Stress And Environment

Question 1

Prodromal phase of psychotic disorders/clinical high risk states

Answer 1

1. Attenuated psychotic symptoms (deviate from normal but not frankly psychotic)
2. Brief intermittent psychotic symptoms lasting less than a week
3. Genetic risk and functional decline

Question 2

Positive symptoms of psychotic disorders

Answer 2

1. Hallucinations (perceptions in absence of stimulus, hearing voices or seeing things)
2. Delusions (disturbances in thought content with a false belief that a person holds true despite evidence to the contrary)
3. Disorganized speech (loose associations, tangentiality, word salad)
4. Disorganized behavior (silliness, aggression, catatonia)

Question 3

Negative symptoms of psychotic disorders

Answer 3

Blunting of affect
Alogia (decreased speech output)
Avolition: lack of self initiated purposeful activities
Anhedonia
Asociality

Question 4

DDx: schizophrenia vs schizophreniform vs brief psychotic disorder

Answer 4

Schizophrenia: at least 2 of 5 key symptoms (1 must be hallucinations, delusions, or disorganized speech. Also may include negative symptoms or disorganized behavior)

Schizophrenia 1 month of active symptoms and 6 months functional impairment

Schizopheniform functional impairment more than 1 month but less than 6 months

Brief psychotic disorder less than 1 month followed by complete remission, often linked to trauma

Question 5

Differential diagnosis: psychotic disorders vs normal

Answer 5

Common for children especially less than 13 to have psychotic like symptoms

Features of normal: absence of premorbid difficulties, auditory hallucinations that are non bizarre and related to stressors, absence of delusions, perceptual disturbances that have less impact on behavior, maintenance of social and academic functioning

Question 6

Differential diagnosis psychotic disorders and ASD

Answer 6

Lack of reciprocity, flat affect, language delay can be thought of as negative symptoms

Thought content may include preoccupation with fantastic or magical ideas

Question 7

Management of high risk/prodromal state of psychotic disorder

Answer 7

Antipsychotics no benefit. SSRI may have benefit

Psychosocial: CBT, cognitive remediation, family psychoeducation

Question 8

Management of psychotic disorders

Answer 8

Meds: antipsychotics

Psychosocial: CBT, cognitive remediation, family psychoeducation

Question 9

DDx somatic symptom disorder and medical condition

Answer 9

Somatic symptom disorder feature is psychological distress. This distress is separate from a medical diagnosis, so a medical diagnosis does not negate possibility of somatic symptom disorder

Question 10

Somatic symptom disorder

Answer 10

1 or more somatic symptoms that are distressing or result in significant disruption of daily life. (May be more than 1 symptom and may change over time)

Excessive thoughts/feelings/behavior related to symptom: disproportionate/persistent thoughts about seriousness, high level of anxiety about symptoms or health, excessive time/energy devoted to

Greater than 6 months

Question 11

Illness anxiety disorder

Answer 11

Preoccupation with having or acquiring a serious illness

No somatic symptoms or if present mild intensity. If medical condition present or risk of condition, preoccupation is out of proportion

High level of anxiety about health, excessive health behaviors (checking for signs of illness) or avoidance of doctors

Preoccupation for at least 6 months, though the health condition can change

Question 12

DDx somatic symptom disorder and illness anxiety disorder

Answer 12

Illness anxiety disorder does not have somatic symptoms present

Question 13

Conversion disorder = functional neurological symptom disorder

Answer 13

1 or more symptoms of altered voluntary motor or sensory function (weakness/paralysis, abnormal movements, swallowing/speech, seizures, sensory loss, special senses=hearing,vision)

Incompatibility between symptoms and recognized conditions

Question 14

Psychogenic non epileptic seizure vs epilepsy

Answer 14

Unusual to see less than 10 years

Associated with psychological trigger (stressor, trauma, conflict) and dissociative symptoms

Features of PNES: forward pelvic thrusting, side to side head and body movements, closed eyes resistant to opening, lack of postictal confusion

May co occur with epilepsy, can get an EEG

Question 15

10 common signs of dissociation in children

Answer 15

1. Amnesia for significant or traumatic events
2. Frequent dazed or tranced states (blank staring and lack of connection to surroundings)
3. Forgetting previously mastered concepts
4. Regression
5. Difficulties with cause and effect consequences from life experience
6. Lying or denying misbehavior despite obvious evidence
7. Repeatedly referring to oneself in 3rd person
8. Unexplained injuries or recurrent self injurious behavior
9. Vivid imaginary companionship involving control of child’s behavior
10. Auditory and visual hallucinations

Question 16

Example of normal dissociative episode

Answer 16

4 year old playing with imaginary friend or other fantasy behaviors that are short lived and can integrate normal streams of consciousness

Question 17

Dissociative identity disorder

Answer 17

2 or more distinct personality states with marked discontinuity in sense of self and agency plus alterations in affect, behavior, consciousness, memory, perception and cognition

Question 18

Dissociative amnesia

Answer 18

Inability to recall important autobiographical information usually if a traumatic or stressful nature

Question 19

Depersonalization/Derealization disorder

Answer 19

Depersonalization = experiences of unreality, detachment or being an outside observer with respect to thoughts, feelings, sensations, body or actions

Derealization: experience of detachment with respect to surroundings

Question 20

Lifetime prevalence of depression in adolescents

Answer 20

11-15%
1/7

Question 21

Gender, age, and depression risk

Answer 21

Risk increases with age
In childhood gender balanced, after puberty more girls

Question 22

One of the strongest predictors of depression

Answer 22

Parent with depression: 1st degree relative with depression risk is 31-42%

Question 23

Presentation of depression in young children

Answer 23

Somatic complaints
Irritable (rather than sad) mood

Question 24

Depressive episodes and recurrence

Answer 24

Average episode 27 weeks
80% have recurrence
Longer the remission, lower the recurrence risk
Risk factors for recurrence: younger age, multiple episodes, more severe episodes

Question 25

Major depressive disorder criteria, time frame, and symptoms

Answer 25

Lasting at least 2 weeks Depressed mood AND/OR anhedonia PLUS At least 5 of: Change in sleep patterns Feelings of guilt/worthlessness Decreased energy/fatigue Decreased concentration, indecisiveness Changes in appetite Psychomotor retardation/agitation Suicidal ideation

Question 26

Persistent depressive disorder criteria, time frame, and symptoms

Answer 26

At least 1 year Persistent dysphoric mood and at least 2 of: Loss of interest Change in appetite Change in sleep Low energy/fatigue Low self esteem Decreased concentration/indecisive Hopelessness

Question 27

Disruptive mood dysregulation disorder criteria and time frame and ages to diagnose

Answer 27

Severe recurrent verbal and/or behavioral outbursts at least 3 times per week PLUS Persistent angry/irritable mood most of the day nearly daily in at least 2 settings for 1 year without break longer than 3 months Symptoms present by age 10, don’t diagnose before 6 or after 18

Question 28

3 evidence based psychotherapies for depression

Answer 28

CBT IPT DBT

Question 29

Cognitive behavioral therapy

Answer 29

Connect relationship between thoughts, feelings, and behaviors Targets behavioral activation and challenging cognitive distortions

Question 30

Interpersonal psychotherapy

Answer 30

For depression: Recommend for severe depression, comorbid anxiety, or high conflict with parents and peers Helps improve problem solving in relationships

Question 31

Dialectic behavior therapy

Answer 31

Targets treatment engagement, emotion regulation, distress tolerance For self harm and NSSI

Question 32

Keys that differentiate a bipolar disorder

Answer 32

1) decreased need for sleep over repeated days that is a significant change from baseline without explanation and feels well rested 2) grandiosity 3) hypersexuality 4) lack of judgment or insight

Question 33

Red flags for bipolar disorder in adolescents

Answer 33

Rage outbursts Verbal or physical aggression Little sleep Spontaneous mood changes Running away Spending money impulsively Hyper sexuality Grandiosity Agitation/mania with SSRI

Question 34

Manic episode criteria

Answer 34

At least 1 week Abnormally elevated or expansive or irritable mood and increased energy or goal directed behavior At least 3 associated symptoms: grandiosity/inflated self esteem, decreased need for sleep, racing thoughts/flight of ideas, distractibility, increased talkativeness, psychomotor agitation, impulsivity/reckless behavior, involvement in pleasurable activity with high risk of consequences

Question 35

Hypomanic episode vs manic episode

Answer 35

Manic at least a week, hypomanic at least 4 days (hypomanic can be shorter) Less severe and does not impact functioning as extremely

Question 36

Bipolar I vs Bipolar II

Answer 36

Bipolar I at least 1 manic episode Bipolar II at least 1 major depressive and 1 hypomanic

Question 37

Major depressive episode criteria

Answer 37

At least 2 weeks Major depressive disorder symptoms (depressed mood and/anhedonia and at least 5) -change in appetite -change in sleep -psychomotor retardation/agitation -low energy/fatigue -decreased concentration, indecisiveness -guilt/wothlessness -suicidality

Question 38

Cycylothymic disorder criteria

Answer 38

Hypomania and major depressive symptoms that don’t meet criteria for bipolar disorder over at least 1 year, no period of stable mood at least 2 months at a time

Question 39

First line treatment for bipolar disorder

Answer 39

2nd generation antipsychotics (aripiprazole) Lithium second line

Question 40

Most powerful predictor of suicide

Answer 40

Prior suicidal behavior (includes suicide attempts and NSSI)

Question 41

Suicide screeners

Answer 41

ASQ questions Columbia

Question 42

Elements of suicide safety plans for youth and caregivers

Answer 42

Youth: 1) elicit 3 strengths about self and family/environment 2) emotional thermometer to understand emotional reactions 3) engage in identifying behaviors, thoughts and interpersonal strategies that can be used instead of self harm 4) list of at least 3 support people 5) commitment from youth Caregiver 1) elicit 3 strengths about youth and family/environment 2) explain importance of lethal means restriction and immediate steps for safety 3) work to support youth and caregiver in using the safety plan

Question 43

Most common reasons for nonsuicidal self injury

Answer 43

Reduce negative emotions and stress Resolve interpersonal difficulty

Question 44

Onset and risk factors for nonsuicidal self injury

Answer 44

Onset 12-16 Increased risk in sexual minority youth Social exclusion and bullying

Question 45

4 presentations of anxiety that could look like other things

Answer 45

1) refusal behaviors/oppositionality 2) poor concentration/inattention 3) somatic complaints 4) irritability

Question 46

Temperament associated with anxiety

Answer 46

Behavioral inhibition, slow to warm

Question 47

Anxiety and family factors (genetics and environment)

Answer 47

1st degree relative 4-6x more likely Heritability 30-50% Parental overprotection and parental modeling (anxious parent, anxious child in bidirectional relationship)

Question 48

Separation anxiety key features and duration

Answer 48

Normal developmental response 10mo to preschool Fear of separation from home/caregiver or something bad happening to caregiver Can present with behavioral outbursts or physical symptoms Duration at least 4 weeks

Question 49

Social anxiety key features and duration

Answer 49

Fear of drawing attention to or embarrassing self in front of peers Duration at least 6 months

Question 50

Most common anxiety disorder in adolescents

Answer 50

Social anxiety disorder

Question 51

Specific phobia duration and key features

Answer 51

Fear of specific object or situation that provokes immediate anxiety and is avoided or endured with fear/anxiety In children can present as crying, tantrums, freezing, clinging Duration at least 6 months

Question 52

Generalized anxiety disorder key feature and duration

Answer 52

Excessive anxiety and worry about a number of events/activities (avoidance of things typical peer would do), difficult to control worry Other features: restlessness/on edge, easily fatigued, difficulty concentrating, irritability, muscle tension, sleep disturbance At least 6 months

Question 53

Selective mutism key features duration and diagnosis

Answer 53

Failure to speak as expected in social situations despite talking in other situations (at home with family) More common in younger children and more apparent on entry to school May use nonverbal skills, may have history of language delay (but not due to communication disorder) At least 1 month, not during first month of school Diagnosis made with behavioral ratings from parents, teachers, and other individuals

Question 54

Panic disorder key features

Answer 54

Recurrent unexpected panic attacks or panic attack followed by at least a month of worry about more attacks or maladaptive behavior changes related to attacks (avoiding settings) Attacks: Abrupt surge in fear or discomfort that peaks within minutes. Physical symptoms (palpitations, heart racing, sweating, shaking, trembling, shortness of breath, chest pain, feeling of choking, nausea/abdominal distress, dizzy/lightheaded, chills or heat feeling, numbness/tingling) Depersonalization/derealization Fear of losing control or fear of dying

Question 55

Obsessive compulsive disorder

Answer 55

Obsessions AND/OR compulsions Must be time consuming (more than an hour a day)

Question 56

Obsessions

Answer 56

1) recurrent and persistent thoughts, urges, or images that are intrusive and inappropriate; cause marked distress or impairment 2) attempts to suppress or ignore these or neutralize with some other thought or action

Question 57

Compulsions

Answer 57

1) behaviors that individual feels compelled to perform in response to obsession or rules that individual thinks must adhere to 2) repetitive behaviors or mental actions done to prevent or reduce dreaded situation

Question 58

Differential ASD and OCD

Answer 58

In ASD repetitive behaviors not tied to attempt to reduce anxiety about specific situation

Question 59

Elements of CBT for anxiety

Answer 59

1) psychoeducation 2) skills training for somatic manifestations, relaxation 3) cognitive restructuring 4) exposure via desensitization, habituation 5) relapse prevention

Question 60

Exposure and response prevention

Answer 60

Graduated exposure to anxiety provoking stimuli and preventing compulsive behavior

Question 61

Behavior therapy for anxiety

Answer 61

Graduated/gradual exposure to fear stimulus focused on decreasing avoidance

Question 62

Treatment of anxiety disorders

Answer 62

First line is CBT CBT plus SSRI for moderate to severe

Question 63

Reasons for school refusal

Answer 63

Anxiety (any type of anxiety disorder) Depression Learning disability Social concerns (lack of friends, bullying, parental illness or separation)

Question 64

Management of school refusal

Answer 64

First figure out what is causing it address it (eg CBT for anxiety) Psychoed: why avoidance of school makes anxiety worse Good daily routine *Return to school plan: can be 1–2 classes per day, no reinforcement at home, safe location to go for few min if super anxious

Question 65

School refusal vs truancy

Answer 65

Truancy is related to conduct disorder School refusal related to anxiety

Question 66

Adjustment disorder timing

Answer 66

Arise within 3 months of stressor Resolve within 6 months. After 6 months: If symptoms persist beyond the stressor, change the diagnosis. If the stressor persists, then chronic adjustment disorder

Question 67

Differential diagnosis of adjustment disorder

Answer 67

Normal stress response or bereavement Another mood or behavior diagnosis (won’t have the clear stressor) Trauma or stressor disorder (stress response significant and characteristic of)

Question 68

Types of adjustment disorder

Answer 68

Anxiety Depressed mood Anxiety and depressed mood Disturbance of conduct Disturbance of emotions and conduct Unspecified (social withdrawal, decline in academics)

Question 69

Primary, secondary, and tertiary treatment and prevention for adjustment disorders

Answer 69

1. Build resiliency, language development, promoting relationship 2. At risk kids (nurse/counselor visits) 3. Relaxation/visualization, CBT, creative expression, family counseling. Think about the setting (school, home, peers). No pharmacotherapy

Question 70

SSRI mechanism of action

Answer 70

Selectively block serotonin reuptake. Increases amount of time serotonin can act on post synaptic sites. Also downstream effects (full effect weeks after initiation) with increase in brain naturetic peptide and modifications to serotonin receptor

Question 71

When and how to start SSRI and when does it start to work

Answer 71

Start if symptoms continue with 6 weeks of CBT alone or can start in combo with CBT for moderate to severe. Start and low dose and increase every 2-3 weeks monitoring for effectiveness and side effects Start to show positive effects within 4-8 weeks and some positive results as early as 1-2 weeks

Question 72

GI side effects from SSRIs

Answer 72

Nausea, vomiting, diarrhea, cramping due to gut serotonin receptors. Usually resolves in 2-4 weeks and a slow titration helps

Question 73

Behavioral activation from SSRI: features and management

Answer 73

Hyperactivity, restlessness, irritability, disinhibition, impulsivity after starting SSRI Most common in prepubescent Manage by decreasing dose, discontinuing or changing medication

Question 74

Black box warning for SSRI

Answer 74

Increased suicidal thoughts or actions For first 9 days after starting or increase in dose, 4% vs 2% with placebo. No completed suicides Not a reason not to prescribe, increased prescription actually decreases suicide rates

Question 75

Serotonin syndrome triad

Answer 75

1) Mental status changes 2) autonomic hyperactivity 3) neuromuscular abnormalities

Question 76

How and when to discontinue or switch an SSRI

Answer 76

Continue 6-12 months after remission of symptoms If no or partial response after 6-8 weeks switch To discontinue/switch taper over 1-2 months to avoid withdrawal symptoms.

Question 77

SSRI withdrawal symptoms

Answer 77

The longer the half life the less likely to experience withdrawal Dizziness/lightheadedness Fatigue/drowsiness

Question 78

SSRIs approved for depression and ages

Answer 78

Fluoxetine 8 and up Escitalopram 12 and up

Question 79

SSRIs approved for anxiety and ages

Answer 79

OCD: sertraline 6 and up, fluoxetine 7 and up, fluvoxamine 8 and up Generalized: escitalopram 7 and up (new as of 5/2023) Duloxetine (SNRI) approved for GAD 7 and up

Question 80

What SSRI should you prescribe if worried about missed doses?

Answer 80

Fluoxetine Long half life

Question 81

Which SSRI has more side effects and withdrawal symptoms

Answer 81

Paroxetine (Anticholinergic side effects)

Question 82

Key differences DMDD vs ODD vs IED

Answer 82

DMDD temper outbursts not necessarily related to being argumentative or defiant (poor frustration tolerance out of proportion). IED also can be provoked by a lot of things and can be verbal/physical w/o property destruction or with. IED is also more impulsive, not premeditated. ODD had losing temper/anger but also argumentative/defiant/vindictive/blaming others or annoying them. In DMDD outbursts occur at least 3 times per week for at least 12 months. In ODD if less then 5 yrs on most days but if 5 or older can be 1x/wk for 6 months. IED w/o damage 2xwk for 3 months, with damage 3x in 3 months Ages: DMDD and IED not before 6 DMDD has the mood component (angry/irritable mood persistent between outbursts). Not true with ODD and IED Overall DMDD is more severe and if criteria met for both its DMDD

Question 83

Aggression in infants

Answer 83

Often developmentally appropriate exploration of environment. Also biting with teething and frustration. Calm correction, provide alternatives, provide practice of skills

Question 84

Aggression in toddlers

Answer 84

Often result of strong emotions without effective language or emotional self control Provide warnings for transitions, social stories, remain calm, identify child’s feeling and goals and for older kids point out consequences l. Manage expectations and praise small steps

Question 85

Aggression in older children and teens

Answer 85

Result of poor social problem skills and lack of behavioral self awareness Interventions parent behavior management training and CBT Impact of media exposure: violent media leads to aggressive behavior and desensitizes violence

Question 86

Thumb sucking -when to treat -management

Answer 86

Don’t treat if 4 or younger (only thing is positive behavior support) Tx: positive behavior support, habit reversal, orthodontic appliances, barrier (glove, splint), chemical nail polish. Behavioral has most evidence

Question 87

Hair pulling

Answer 87

< 6 years: usually self limited habit. Older children and adolescents: more chronic and associated with anxiety, depression Tx habit reversal, blocking, positive reinforcement. SSRI and NAC in adults

Question 88

Nail biting

Answer 88

Can be due to anxiety but also boredom and frustration Treatment is behavioral intervention and good nail hygiene

Question 89

Picking of skin and nose

Answer 89

Management by blocking access SSRI and NAC have shown improvements

Question 90

Head banging

Answer 90

5-19% of infants and toddlers. Often at bedtime or when frustrated Provide reassurance, ignore behavior Pad surfaces If more severe and persistent with developmental disability, helmet or meds

Question 91

Habit reversal therapy

Answer 91

Increase awareness of habit Teach competing response to habit Review associated problems

Question 92

Breath holding spells Types, differential, and management

Answer 92

Cyanotic: often preceded by anger frustration leading to intense crying. Pallid: more likely to be provoked by fear or pain. Less crying. Can be mixed DDx vs medical cause: provoking factor and color change Treatment reassurance

Question 93

Psychogenic illness: important first step

Answer 93

Acknowledge reality of patients experience/symptoms Avoid phrases like “there’s nothing wrong with you”

Question 94

Stress response in the brain (And difference between stress types)

Answer 94

Stress activates PFC and hippocampus PFC and hippocampus stimulate amygdala Amygdala activates HPA HPA releases cortisol Tolerable stress: cortisol rise is transient, levels return to baseline through negative feedback loop Toxic stress: amygdala can’t be inhibited, negative feedback loop is not effective, cortisol chronically high

Question 95

Exposure to violence: signs in young children/preschoolers

Answer 95

Difficulty with sleep Difficulty with separation Somatic complaints (in older preschoolers)

Question 96

Exposure to violence: signs in school age

Answer 96

Anxiety Aggression Poor sleep Poor school functioning

Question 97

Child abuse risk factor with greatest risk of death

Answer 97

Age (<3)

Question 98

Most common form of child maltreatment

Answer 98

Neglect (Children living in poverty 12x more likely to experience)

Question 99

Signs of emotional/psychological abuse

Answer 99

Internalizing (anxiety, depression, shame, perfectionism) Externalizing (aggression, hyperactivity, oppositional/defiant, inappropriate, irresponsible, provocative) Signs of disorganized attachment: clinginess, social disinhibition

Question 100

Signs during a visit that may be concerning for neglect and what to do:

Answer 100

Developmental delay, lack of parental knowledge about development, attachment issues What to do: screen for parental depression

Question 101

Steps to take after a disaster

Answer 101

First is meet basic needs: food, shelter, safety, supervision. Mental health screening and support is also critical What to ask about? —> ask what they already know and have heard (look for misinformation, misunderstanding, misconceptions); ask about worries/questions/concerns; don’t minimize concerns, listen actively and emphatically; provide info in simple and direct terms; identify risk factors for adjustment problem; offer coping strategies; get back into routine Refer for behavior support Provide guidance on what may be seen (sleep problems, eating changes, depression, anxiety, difficulty concentrating, substance use, risk taking behavior, somatic symptoms, developmental or social regression) and that can worsen preexisting issues (financial problems, parental mental health)

Question 102

Relational aggression

Answer 102

Bullying behavior causing harm within relationships at the individual or group level (spreading rumors, exclusion, threat to stop talking to) Victims are more likely to experience peer rejection, have poor peer relationships, fewer prosocial problem solving skills Aggressors more likely to be popular and use aggression to advance or protect their status. They also may have poor psychological and social adjustment, poor academic performance.

Question 103

Ostracism

Answer 103

When person is ignored and made to feel non existent. Consist of withdrawing eye contact with, response to, and recognition of another person. Consequences may include sadness, hurt feelings, change in social perception (interpreting ambiguous situations as threatening)

Question 104

Risk factors for adjustment difficulties after a disaster

Answer 104

1) Previous psychopathology 2) Significant losses or other traumatic events 3) attachment disturbances 4) socioeconomic differences (level of post disaster resources and support) 5) nature of the disaster (injury of child or injury/death of those close to child, nature and extent of exposure (human made create more prevalent and long lasting reactions), extent of exposure (even indirect through media), child’s perception at the time of the event that life in jeopardy 6) subsequent factors (separation from caregivers, loss of property or belonging/need to relocate, parental difficulties coping/mental health/substance abuse), lack of supportive family communication style, lack of community resources/support)

Question 105

Concepts related to death (and age of understanding)

Answer 105

Age 5-7 Irreversibility: death is permanent Finality: no life functions (can’t be cold, in pain, or hungry) Inevitability: natural phenomenon, no one is immortal Causality: realistic causes of death (not caused by child’s own thoughts or actions) Guilt is commonly expressed after death of someone close (what they did or failed to do to contribute)

Question 106

Response to death: age 3-5

Answer 106

When’s my mom coming home? Preoperational thinking, difficulty understanding illness and permanence of death. Give scripts to explain

Question 107

Response to death age 6-8

Answer 107

“I think I killed her” Late preoperational thinking with both magical and logical thinking. Better understanding of permanency of death. Simple explanations about causal relationship, discuss prognosis when death imminent Children may make logical errors when misunderstanding cause and effect

Question 108

Response to death age 9-11

Answer 108

“Just give me the facts” Concrete operational thinking. Better able to use logical thinking and cause and effect, Benefit from detailed, concrete explanations of disease and treatment

Question 109

Response to death age 12-14

Answer 109

“I cry in my room alone” Inconsistent formal operational thinking. May be egocentric and callous

Question 110

Response to death age 15-17

Answer 110

“So much has changed, nothing will be the same again” Consistent formal operational thinking, grief similar to adults. More allocentric and empathic

Question 111

Reactive Attachment Disorder

Answer 111

Consistent pattern of emotional withdrawal toward others including minimal response to comfort from caregiver or lack of seeking comfort in time of stress Symptoms: limited social/emotional responsiveness toward others, limited expression of positive affect, periods of irritability/sadness/fear during nonthreatening adult interaction. History of insufficient care: neglect, multiple changes Symptoms appear before age 5 and developmental age at least 9 months With stable/supportive environment, can develop new patterns Intervention: therapy If untreated, higher rates of psychopathology DDx: ASD would have RRBs Trauma disorder would have specific event

Question 112

Traumatic event for PTSD

Answer 112

Exposure to actual or threatened death, serious injury, or sexual violence by: 1) direct exposure 2) witnessing 3) learning about events to close family member/friend

Question 113

Symptom clusters in PTSD

Answer 113

1) Intrusion: distressing memories, dreams, flashbacks, dissociation, prolonged psychological distress or physiological reactions to cues 2) avoidance: avoidance of distressing memories/thoughts/feelings or of external reminders 3) mood/cognition: inability to remember aspects, exaggerated negative self beliefs, distorted sense of blame, persistent negative emotional state, feels of detachment, decreased participation 4) arousal/reactivity: irritable behavior/anger outbursts, reckless or self destructive behavior, hyper vigilance, exaggerated startle, problems with concentration, sleep disturbance

Question 114

Diagnosis of PTSD in children 6 and under vs older

Answer 114

Diagnosis is 1 intrusion + 1 avoidance + 2 mood/cognition + 2 arousal/reactivity In children 6 and under: 1 intrusion + (1 avoidance OR 1 mood/cognition) + 2 arousal/reactivity

Question 115

Duration differences in acute stress vs PTSD

Answer 115

Acute stress: 3 days to 1 mo PTSD: greater than a month

Question 116

Risk factors for PTSD

Answer 116

Previous history of anxiety Women > men Type of event: violence/abuse > natural disasters Severity and chronicity of trauma Environment after traumatic event (lack of support, ongoing adversity) increases risk of chronic PTSD symptoms

Question 117

Treatment PTSD

Answer 117

***trauma focused CBT Child parent psychotherapy in under 6

Question 118

CMV neurodevelopmental outcomes

Answer 118

Leading nongenetic cause of SNHL, progressive over childhood even in infants without signs at birth Increased risk of CP, developmental delays, autism. Intracranial findings increases risks

Question 119

Name the congenital infection -Fever, rash, chorioretinitis, intracranial calcification, hydrocephalus -at risk for vision loss, hearing loss, seizures, cognitive and motor delays

Answer 119

Toxoplasmosis Most (80-90%) asymptomatic Caring for cats

Question 120

Name the congenital infection : -cataracts, congenital heart defects, SNHL, microcephaly

Answer 120

Rubella Heart defect: PDA High perinatal mortality rate and preterm birth Rare in US —> unvaccinated or outside US

Question 121

Name the congenital infection: -rash desquamation involving palms and soles, jaundice, hepatosplenomegaly, rhinitis, skeletal abnormalities -vision/hearing loss, CP, seizures, cognitive delay, speech/language delay -late: bone pain, retinitis pigmentosa, peg shaped upper central incisors, interstitial keratitis, saddle nose

Answer 121

Syphilis Most infants are symptom free On the rise in US and persists in low income countries

Question 122

Name the congenital infection -rashes, CNS findings (hydrocephalus, white matter lesions, seizures, encephalitis), ophthalmologic -vision loss, severe motor and neurologic impairment

Answer 122

HSV True congenital infection rate (neonatal/perinatal)

Question 123

Congenital infection that causes fetal anemia

Answer 123

Parvo B19

Question 124

Name the congenital infection: -skin lesions, neurologic and eye defects, limb hypoplasia -symptoms at birth associated with later developmental/behavioral outcomes

Answer 124

Varicella

Question 125

Name the congenital infection -severe microcephaly, brain and ocular abnormalities, congenital contractures, seizures, spasticity

Answer 125

Zika Mosquito bite aedes species (central/South America, Southeast Asia, Africa) Cognitive outcomes associated with head circumference at birth

Question 126

How to screen for iron deficiency

Answer 126

Ferritin and inflammatory marker, Hb checks anemia which is a late finding Can have cognitive/developmental impacts without anemia Early treatment of iron deficiency does not lead to complete brain recovery

Question 127

Nutrient critical for thyroid hormone synthesis and risks if deficient

Answer 127

Iodine Severe deficiency in first trimester: cretinism. IQ 30 with deficits in hearing, speech, and gait Improvement with supplementation before 10 weeks

Question 128

Nutrient essential for myelination and neuronal development, common reasons for deficiency, and symptoms of deficiency

Answer 128

B12 Maternal: pernicious anemia, strict vegetarian diet, gastric bypass Symptoms at 4-10 months: failure to thrive, developmental regression, tremors, hypotonia, lethargy, irritability

Question 129

Alcohol mechanism of harm (and when most harmful)

Answer 129

Interference with neuronal migration, impaired development and function of neurotransmitter receptors, neuronal necrosis, reduced brain volume Harmful at all stages. First trimester, most likely to be associated with facial anomalies and major structural abnormalities.

Question 130

Definition of documented alcohol exposure (5 things)

Answer 130

1. Six or more drinks per week for two or more weeks. 2. Three or more drinks per occasion on two or more occasions. 3. Documentation of alcohol use on a screening instrument during pregnancy. 4. Alcohol related, social or legal problems. 5. Positive test.

Question 131

Criteria for fetal alcohol syndrome (Including classic facial features)

Answer 131

*** can diagnose in absence of documented exposure A) at least two facial features (short palpebral fissures, thin vermillion border/upper lip, smooth philtrim) B) growth deficiency C) structural neurologic or functional central nervous system abnormalities D) Neuro behavioral impairment, characterized by cognitive impairment and or behavioral impairment and for younger children, developmental delay (emotional dysregulation, ADHD symptoms, learning and memory problems)

Question 132

Criteria for partial fetal alcohol syndrome (with and without documented exposure)

Answer 132

With documented exposure: A) two facial features, D) Neuro behavioral Without documented exposure : A) two facial features; B) growth deficiency OR C) structural neurologic or functional CNS abnormality; D) Neuro behavioral impairment

Question 133

Criteria for alcohol related neurodevelopmental disorder

Answer 133

Documented exposure + D) Neuro behavioral impairment Cannot diagnose less than three years

Question 134

Most common Neuro developmental disorders associated with fetal alcohol syndrome

Answer 134

ADHD (50%) Intellectual disability (23%) Learning disability (20%) Oppositional, defiant disorder (16.3%) Anxiety and depression (14.1%)

Question 135

Nicotine exposure -mechanism -DBP outcomes

Answer 135

Mechanism: interference with signaling among progenitor cells during brain development, epigenetic effects may play a part Outcomes : ADHD, conduct problems, depression, and anxiety, SNHL

Question 136

Valproic Acid effects

Answer 136

Neural tube defects Dysmorphic craniofacial features Microcephaly Congenital heart disease Limb abnormalities GU abnormalities Developmental delay is especially speech and language Decreased full scale, IQ, with verbal more affected then nonverbal Deficits of working memory Increased autism spectrum disorder Increased ADHD

Question 137

SSRI exposure Mechanism and outcomes

Answer 137

Mechanism: affect HPA axis, and induce epigenetic changes Increased pre-term birth, lower birth weight Neonatal behavioral syndrome due to effects of withdrawal or increased serotonergic tone (hypothermia, vomiting, frequent stools, feeding difficulties, poor sleep, excessive, crying, agitation, irritability, tremors, seizures, hypoglycemia, hypertonia, hyperreflexia) Lower psychomotor developmental scores, increased ASD though studies show variable outcomes Untreated maternal depression may itself negatively affect child’s development, consider risk versus benefit of continued treatment

Question 138

Lithium exposure effects

Answer 138

Perinatal toxicity (hypotonia, heart failure, nephrogenic DI) Ebstein’s anomaly (tricuspid valve disease)

Question 139

Cocaine exposure: mechanism and outcomes

Answer 139

Peripheral vasoconstriction leads to decreased blood flow to the placenta which affects intrauterine growth Increased dopamine activity in the fetal brain affects neural migration. Frontal lobes, particularly vulnerable. Poor cognitive and speech and language skills increased learning disabilities, externalizing behavior

Question 140

Opioids exposure: mechanism and outcomes

Answer 140

Altered levels of neurotransmitters, altered neurogenesis IUGR , small fetal heads circumference, neural tube defects, congenital heart defects Delays in cognitive motor and speech, language development, lower IQ and academic achievement, increased attention and behavior problems. However, difficult to determine if long-term effects solely due to opioid or multiple confounders. Neonatal opioid withdrawal syndrome : excessive, crying, poor sleep, hyperactive Moro, tremors, myoclonus, increased muscle tone, excretion, modeling, fever, nasal, stuffiness, sweating, difficulty breathing for feeding vomiting, diarrhea, failure to thrive, excessive irritability)

Question 141

Cannabis exposure: outcomes

Answer 141

Limited literature on CBD effects Lower birth, weight, executive functioning deficits, poor, academic achievement, increased hyperactivity, impulsivity, and in attention, increased delinquency, depressive symptoms

Question 142

Amphetamines exposure: mechanism and outcomes

Answer 142

Methamphetamine neurotoxic effects on dopamine and epinephrine containing cells and affect areas of the brain associated with attention and behavior Imaging abnormalities in frontal right matter and smaller subcortical volumes in the putamen, globus pallidus, and hippocampus Increased externalizing and rule, breaking and aggressive behaviors

Question 143

Lead -reference value -most common source -outcomes

Answer 143

5mcg/dL Lead laden dust and paint chips Outcomes: long lasting sequela on intellectual and academic achievement later in childhood, even after low level exposures. Cognitive damage, hearing loss, visual effects, delayed speech, learning disabilities, decreased reading in math skills, poor attention, executive functioning deficits.

Question 144

Mercury -source -outcomes

Answer 144

Severe poisoning has become rare. However, a more insidious concern is of chronic exposure, resulting from contamination of the food chain, especially certain species of fish. Methylmercury is a potent neurotoxin and the adverse effects include dose related reduction and IQ, shortened detention span, irreversible, neurologic, and developmental effects More recent concern is on more subtle neurocognitive effects that may be attributed to chronic low level exposure Recommend no more than one serving per week of albacore, tuna, swordfish, shark, king, mackerel, and, Spanish mackerel

Question 145

Organophosphate -mechanism -outcomes

Answer 145

Inhibit activity of acetylcholinesterase Damage to cognitive abilities, changes in behavior and developmental delays, higher rates of autism and ADHD even low to moderate levels of exposure associated with persistent changes in brain structure and function

Question 146

Name the congenital infection -rash, jaundice, thrombocytopenia, hepatosplenomegaly, SGA, microcephaly, periventricular calcifications, hearing loss

Answer 146

CMV 90% asymptomatic at birth Hearing loss not always present at birth, onset delayed in up to 40%.

Question 147

CMV diagnosis

Answer 147

Screening for congenital CMV has become more common and is mandated in some states typically after failure of newborn hearing screen Definitive diagnosis requires proof of viral presence in the newborn period. Urine blood or salivary samples in the first 21 days confirmed by PCR.

Question 148

CMV management

Answer 148

If infant is symptomatic during the first month, antiviral treatment can be effective in reducing hearing loss and developmental and cognitive disabilities risk with antiviral treatment is neutropenia If diagnosed audiology and ophthalmology are warranted . Audiology every 3 to 6 months until age 3, and then annually until at least age 6.

Question 149

Isoretinoin exposure

Answer 149

Cranial facial abnormalities (cleft palate, ear abnormalities, micropthalmia, micrognathia, abnormally shaped skull, microcephaly) may affect cardiovascular system thymus parathyroid CNS

Question 150

Substance use risk factors

Answer 150

Genetics Age at first use (younger age) and having friends that use Family history Lack of parental investment in activities of their children Personality: low assertiveness, low self esteem, low self efficacy, low social confidence, external locus of control Social determinants of health

Question 151

CRAFFT screening

Answer 151

Part A: during last 12 months, how many days did you 1) drink more than a few sips of alcohol 2) use marijuana, 3) use anything else to get high Part B If all 0s in part A then ask C only C: have you ever ridden in a Car w someone (including yourself) who was high or using R: have you have used to Relax, feel better about yourself or fit in A: did you ever use Alone F: do you ever Forget things you did F: do your Family and Friends ever tell you to cut down T: have you ever gotten in Trouble

Question 152

Labs/Drug testing

Answer 152

Avoid drug test at request of parents or legal authorities Many use drugs sporadically making lab testing unreliable Serum half lives are brief so urine testing reflects 24-48 hrs with exception THC

Question 153

Treatment of SUD

Answer 153

Psychosocial: CBT, family therapy Family based interventions have most evidence Medical/psychaitric: detoxification, medications (methadone, nicotine replacement), acute or long term residential Long term=highly structured program 30-90 days, some up to a year

Question 154

Substance use disorder criteria

Answer 154

Problematic pattern of use leading to clinically significant distress or impairment manifested by at least 2 of the following in a 12 month period: 2-3=mild, 4-5=moderate, 6=severe 1. Substance taken in larger amount or over longer period than intended 2. Persistent desire or unsuccessful efforts to cut down or control 3. Great deal of time spent in activities to obtain, use, and recover from effects 4. Craving or strong desire to use 5. Recurrent use resulting in failure to fulfill major obligations at work, school, home 6. Continued use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by effects of substance 7. Important social, occupational or recreational activities given or or reduced because of substance use 8. Recurrent use in situations in which it is physically hazardous 9. Continued substance use despite having recurrent physical or psychological problems that is liked to have been caused by or exacerbated by the substance 10. Tolerance: need for markedly more to achieve intoxication OR markedly diminished effect with continued use of the same amount 11. Withdrawal: a characteristic withdrawal syndrome OR substance taken to relieve or avoid withdrawal

Question 155

5 R talking points for brief counseling

Answer 155

1. Review: for each yes response to screener tell me more about that 2. Recommend: not to use “as your doctor my recommendation is not to use XX because they can YYY” 3. Riding: driving risk counseling 4. Response: for non user “if someone asked you why you don’t XYZ, what would you say” and for users “what would some of the benefits be of not using” 5. Reinforce: self efficacy “ I believe you have what it takes to keep use from getting in the way…”

Question 156

What to do if there is cyber bullying

Answer 156

Save examples (descriptions, screenshots, texts, dates and times). Don’t respond to or forward messages and should block the person Can report to internet service providers and social media sites Sending threats of violence, sexually explicit photos or messages, images from a place where privacy is expected along with stalking and hate crimes is criminal and should be reported to law enforcement

Question 157

Benefits of social media use and problems with restricted access

Answer 157

Benefits: identity development, aspirational development, peer engagement, support for those in marginalized communities Restricting social media can increase social withdrawal and isolation

Question 158

Family media plan

Answer 158

Helps families develop rules and guidelines about screen time. Suggestions for screen free times and zones, choosing what media will be used, balancing activities, safety and good digital citizenship

Question 159

Internet gaming disorder -criteria -duration

Answer 159

Disorder in which individuals participate in gaming in a persistent and recurrent manner which can lead to clinically significant distress/impairment 5 of 9 within 12 months: -preoccupation with games -withdrawal when game taken away (irritability, sadness, anxiety) -unsuccessful attempts to reduce or control game participation -loss of interest in real life relationships or activities -continued excessive use despite awareness of psychosocial problems -deceit about amount of gaming to others (family, therapist) -use of games to escape or relieve a negative mood -jeopardized or lost a relationship/job/educational opportunity due to participation

Question 160

Internet gaming disorder -risk factors

Answer 160

Internal: executive functioning and mood/reward system dysregulation, avoidant behaviors, low self esteem. ADHD, depression, social anxiety, ASD External: poor parent and peer relationships, poor parental control and negative role models, family violence, single parent

Question 161

Best way to prevent firearm injury

Answer 161

Complete absence of guns is best. Or limit access (store locked and unloaded) Limited evidence that gun education programs are effective No direct causal link between exposure to violent media and firearm usage or injury. However some children may be more susceptible to exposure to violent media and violent media may desensitize children to violence or normalize violent behavior

Question 162

Parent role (and 3 ways parents can scaffold media consumption)

Answer 162

1. Coviewing: watching show together 2. Instructive mediation: teaching or talking about what children are viewing 3. Restrictive mediation: setting limits and choosing what children view Parents must manage their own behavior

Question 163

Media and health outcomes

Answer 163

Insufficient sleep (recommend limiting screens before bed and limiting screens in bedroom) Obesity Language development: greater media associated with lower language skills; higher quality educational programming and coviewing associated with higher skillls Executive functioning: association between greater media use and challenges with EF, possibly in bi directional way

Question 164

Media recommendations by age: infants

Answer 164

Limit to video chatting and provide ample time for other enriching activities

Question 165

Media recommendations by age: toddlers/preschoolers

Answer 165

Choose high quality educational content and watch together when possible, limit to an hour or less per day

Question 166

Media recommendations by age: school age

Answer 166

Choose high quality educational content, watch together when possible, reflect with your child on digital media and promote digital citizenship, provide ample time for other developmentally enriching activities

Question 167

Media recommendations by age: adolescents

Answer 167

Limit distractions when completing schoolwork, supervision of social media accounts

Question 168

8 Red flags for factitious disorder by proxy

Answer 168

1) History inconsistent with direct observation 2) inconsistent histories from other medical visits 3) recurrent, unexplained, prolonged illness 4) multiple medical visits, tests, interventions 5) multiple symptoms reported by caregiver 6) symptoms only seen by caregiver 7) improvement in symptoms only when away from caregiver 8) siblings of children who have been victims of abuse or factitious disorder

Question 169

If factitious disorder suspected, next step is:

Answer 169

Working with interdisciplinary child protection team (child abuse pediatrician, referral to CPS) Do not confront the parent in the room without gathering past records or consult with child abuse specialist Discontinuing any medical tests or treatments that are not indicated is crucial (don’t do more tests)

Question 170

If a child in a question has a lot of ACEs (parent incarceration, domestic violence, substance abuse, mental illness) and child has behavior issues and parent appears disengaged in a visit, the answer is:

Answer 170

Screen the parent for depression Resilience promoted by safe stable relationships with immediate family

Question 171

Diagnosis of conduct disorder and children, younger than 10

Answer 171

A diagnose of conduct disorder is made when recurring behaviors occur at least one of the following categories for at least 6 months: aggression toward people and destruction of property, lying, and theft, other violations of rules

Question 172

Management of conduct disorder

Answer 172

Prioritize as assessment for and treatment of co-occurring conditions, ADHD anxiety, depression, ODD Behavioral therapy Partner with school and community organizations

Question 173

Understand lying and stealing, age

Answer 173

Age 6

Question 174

Reasons why kids lie

Answer 174

Younger children because they are testing a new behavior I want to boost their self-esteem or gain approval Older children because they don’t want to disappoint their parents

Question 175

Reason why kids steal

Answer 175

Because they want something they do not have or an anger or retaliation

Question 176

Brain changes with toxic stress

Answer 176

Decrease in corpus callosum volume

Question 177

Vegan diet concerns

Answer 177

Often deficient in vitamin B 12, protein, and fatty acids