MENTAL HEALTH Flashcards
What are the 4 primary presentations in ADHD?
Inattention
Hyperactivity
Emotional dysregulation
Impulsivity
What are the top three mental health disorders?
Depression, anxiety and ADHD
5-9% of children and 3-5% of adults are diagnosed with this mental health condition.
ADHD
What might symptoms of inattention look like in a pediatric patient with ADHD?
- Fails to give close attention to details
- Difficulty sustaining attention**
- Does not seem to listen when spoken to directly
- Does not follow through on instructions
- Difficulty organizing tasks and activities
- Avoids or dislikes tasks that require sustained
mental effort - Loses things
- Easily distracted
- Forgetful
What might symptoms of hyperactivity look like in a pediatric patient with ADHD?
- Fidgets with or taps hands and feet
- Leaves seat in situations that require remaining
seated - Runs about or climbs where it is inappropriate
- Unable to play or engage in leisure activities quietly
- Often “on the go”
- Talks excessively
- Has difficulty waiting his or her turn
- Interrupts or intrudes on others
- Blurts out answers
What is the DSM-V criteria for diagnosing ADHD in pediatric patients?
<17 years old : 6+ symptoms
> 17 years old: 5+ symptoms
Symptoms must:
-be persistent for 6+ months
-be present before age 12
-be present in multiple settings (school, home, work)
-interfere with or reduce daily functioning
-not be better explained by another mental health condition
What are some differential mental diagnoses for ADHD?
Conduct disorder
Bipolar disorder
Language disorder
Substance misuse
Sleep disorder
PTSD/stress reaction
What are some differential physical diagnoses for ADHD?
Sensory impairment, esp. hearing
Seizure disorder
Iron deficiency
Environmental toxins (lead)
SE of meds
Hyperthyroidism
Congenital infection
In utero exposure to drugs/ETOH
Brain injury (trauma, infection)
Brain lesions
Sleep apnea
Which mental health disorders are common comorbidities of ADHD?
- Oppositional defiant disorder ~60%
- Specific learning difficulties ~45%
- Speech-language disorder ~40%
- Anxiety ~30%
- Depression ~18%
- ASD 10% (autism spectrum disorder)
- Higher rates of seizure disorder, sleep disorder,
chronic tics/Tourette’s, enuresis, bipolar
disorder, substance use, PTSD
How should you address mental health comorbidities of ADHD?
- Treat the most disabling condition OR the
condition most likely to respond to tx first - Severe depression, unstable bipolar disorder,
active substance use MUST be dealt with first
o Psychosocial treatments
o Medication
o Both - Then treat the other conditions
Untreated ADHD can lead to difficulties in adulthood. Can you name some areas?
Academic concerns
Relationships
Poor self-esteem
Self-harm
Smoking & drug addiction
Traffic accidents
Legal difficulties
Occupational/vocational
What is the rate of childhood victimization in the US? (From Berkowitz text, sorry)
1 in 7
15-20% of these undergo physical abuse
In the context of physical abuse, what is a sentinel injury?
Minor injury under appreciated by the non- offending care taker (and often the PCP) that precedes/ is a warning sign of future more severe injury from physical abuse
i.e., bruise in pre mobile infant, subconjunctival hemorrhage
What are some parental traits that can increase risk of physical abuse?
Unrealistic expectations (frustration and abuse result when unmet)
Poor impulse control
What injury represents the most deadly form of abuse?
Head injuries
How can head injuries result from physical abuse
-Direct blow
-Rotational movement/ shaking
-intracranial hemorrage (shaken baby)
-Diffuse axonal injury (shaken baby)
-Subdural hemorrage (shearing of bridging veins)
-Can lead to apnea, seizures, cerebral edema, hypoxic brain injury, retinal hemorrages
What is the 2nd most fatal form of physical abuse
Abdo trauma, typically causes by blows
What is important to note in history taking in a child presenting with an injury (that may raise alarm for physical abuse)?
-Changing history
-History inconsistent with injuries sustained
-History does not match developmental capabilities of child
-Unwitnessed injuries (esp. in pre- ambulatory kids)
What kinds of bruises are suspicious for physical abuse?
Usually, accidental bruises in children are over bony prominences (forehead, elbow, shins).
Be suspicious of bruises to soft area (cheeks, ear pinna) or protected areas (inner thigh, neck)
What burn patterns should raises suspicion for physical abuse?
-Immersion burns (glove/ stocking/ donut pattern- differs from splash/ spill, which has irregular drip pattern)
-marks that appear to result from hot objects held against child (i.e., cigarette)
What kind of fractures raise suspicion for physical abuse?
-long bone fractures of humerus and femur (esp in preverbal/ preambulatory child)
-metaphyseal lesions
-fractures of rib, sternum, scapula
Name some medical conditions that can mimic abuse.
o Bullous impetigo may resemble burns
o Coagulopathy may results in bruises
o Leukemia, thrombocytopenia, aplastic anemia are associated with bruising
o Osteogenesis imperfecta or rickets may result in many #
o Bone cysts and osteoporosis caused by inactivity (i.e., due to CP, paralysis) may predispose to development of pathological fracture
o Congenital melanocytosis (large blue gray spots on back and buttocks)
What are general treatment measures for children in which you suspect physical abuse?
- Medical stabilization
- Thorough, objective documentation of findings
- Psychosocial investigation (often requires SW)
- May have in home evaluation
- Need to report (even if unsure abuse has occurred)
What is one thing we can do to prevent physical abuse?
- Anticipatory guidance re expected development and expectations (infant colic, toddler toilet training and tantrums)
What are risk factors for intimate partner violence (IPV)
personal hx of maltreatment as child, adolescent or young adult, disparity of status (educational, professional) between partners, high level of dependence of one partner on other, substance use, low self- esteem, pregnancy
What are common clinical presentations for IPV?
- May present for care for themselves or children
- 1/3 of people injured by partner seek care for their injuries
- Skin injuries most common (esp. head, neck, face)
- Patient may fabricate stores to explain injuries
- Children may manifest effects of trauma: stress, disrupted caregiver attachment, anxiety, fear, hypervigilant; may have difficulty with aggression and peer relationships
- Adult or adolescent victims of IPV often present with vague symptoms, and those who have been abused are more likely to present with gyne complaints (recurrent STIs, vaginal bleeding, chronic pelvic pain)
- May also present with non specific symptoms- sleeping difficulties, appetite changes, weight loss, chronic pain, syncope
Describe the cycle of violence in IPV
o Tension building: Abuse uses verbal, emotional, physical threats
o Violent episode: Physical/ sexual/ emotional/ psychological assault
o Honeymoon phase: Abuser apologizes and assures it will not happen again; re-bonding occurs
These escalate over time; violence becomes more frequent and more severe and honeymoon phase shortens
What factors increase the risk of harm in IPV?
o Threats to harm or kill victim or another person
o Use of alcohol or drugs during the incident
o Use of weapon
o Victim reports abuse or attempts to leave relationship
T/ F most people will tell you if they are being abused
False. You need to screen and ask
What is the management for a patient presenting with IPV?
- Safety assessment (pattern of escalating violence, weapons available, comfort level of victim to return home)
- Emergency safety plan
- SW- IPV shelter, hotline, advocacy organization
- Collect money, care keys, house keys, important documents
- Ask neighbors to contact police if violence heard in home
- Establish a code that victim can use to communicate to others violence is occurring that prompts the contact to take certain action on use of code
- Disarming or removing weapons from home
- Need to report child abuse that is occurring; refer child to trauma focused mental health services
Children exposed to IPV have an increase risk of adult morbidity, including….
substance use disorder
obesity
depression
suicide attempts
and many more
Define child sexual abuse
Child sexual abuse involves sexual activity that children/adolescents cannot consent to due to their age/developmental level. Age disparity exists, and the intent is sexual gratification of the older perpetrator. May or may not include physical contact (i.e.. - includes acts of exhibitionism and involvement in pornography)
Differentiated from “sexual play” by the developmental levels of the participants and the coerciveness of the behavior.
What is Canada’s age of consent to sexual activity?
16
Is there any exception to this age of consent?
A 14 or 15 year old can consent to sexual activity as long as the partner is less than five years older and there is no relationship of trust, authority or dependency or any other exploitation of the young person. This means that if the partner is 5 years or older than the 14 or 15 year old, any sexual activity is a criminal offence.
There is also a “close in age” exception for 12 and 13 year olds. A 12 or 13 year old can consent to sexual activity with a partner as long as the partner is less than two years older and there is no relationship of trust, authority or dependency or any other exploitation of the young person. This means that if the partner is 2 years or older than the 12 or 13 year old, any sexual activity is a criminal offence.
Does this mean a 16 year old can consent to sexual activity with anyone?
No
A 16 or 17 year old cannot consent to sexual activity if:
their sexual partner is in position of trust or authority towards them, for example their teacher or coach
the young person is dependent on their sexual partner, for example for care or support
the relationship between the young person and their sexual partner is exploitative
What is the estimated prevalence of child sexual abuse
20-25% of women and 10-15% of men
What is the mean time from onset of sexual abuse to disclosure of abuse?
3 years (due to many reasons - Coercion/threats, feelings of guilt/personal responsibility, not realizing the relationship is harmful initially, fear of family disruption)
Children may not disclose, abuse is incidentally discovered due to symptoms such as vaginal discharge
Who are the most common perpetrators of child sexual abuse?
Often the perpetrators are known by the targets
37% of perpetrators are biological parents
23% non biological parent
How does child sexual abuse often present?
Most cases found when child discloses
May have no physical or behavioral symptoms
Physical symptoms
-anogenital bleeding, pain, swelling, dysuria, vaginal discharge, difficulty passing stool, scarring, STIs, pregnancy
-More common: nonspecific symptoms of headache, abdo pain, fatigue
Behavioral symptoms
-Sleep disturbances, hyperactivity, enuresis, encopresis, decreased appetite, depression, sexualized behavior
-School failure, delinquency, suicide attempts
Should you conduct the history for a child who discloses sexual activity?
Ask thought out, non-leading questions, make effort to have the child questioned a minimal number of times.
Interviews should be performed by someone with professional expertise in the field – could be a care provider, SW, psychologist, rape counselor, detective or attorney.
T/F A normal PE rules out sexual abuse
False
T/F if an episode of sexual abuse occured in the last 72 hours, forensic evidence can be collected.
True
If within 72 hours, forensic evidence should be collected
For adolescents, DNA evidence can be collected up to 120 hours after assault – usually involves vaginal washings of dried secretions and submission of clothing
1-5% of children sexually abused acquire a STI – STI testing based on risk assessment.
Use cultures rather than NAAT, as they hold up better in court
What are some conditions that can be mistaken for sexual abuse?
Genital
-Accidental trauma (i.e., from straddle injury/ falls)
-Lichen sclerosis (hypopigmented figure 8 in anogential area)
-Urethral prolapse (F age 4-8)
-Labial adhesions
-Congenital malformations
-Hemangioma
-Candida (can mimic STI)
Anal
-IBD
-hemorrhoids
-anal or perirectal abcess, strep infection
Outline the general management when caring for children who have experienced sexual abuse.
Address medical problems such as traumatic injuries
Offer adolescents pregnancy counselling, STI prophylaxis and emergency contraception
Crisis intervention through referral to appropriate counselling services
Report disclosure to appropriate agencies
May be required to testify in court – very careful and clear documentatio
What are some components of your physical exam if you are assessing a pediatric patient for ADHD?
Plot growth (HT, WT, head circ.) - growth can be slightly reduced 1-2%.
Inspection for minor congenital anomalies or dysmorphia
Neuro exam including affect, speech, hearing and vision
CVS/Resp
Observation of the child’s behaviour during the office visit
You have just diagnosed a patient with ADHD. If you suspect this patient may have an eating disorder (decreased nutrients), would you still treat with stimulants?
No, stimulants are contraindicated if the eating disorder is severe, especially in adolescents and youth. The brain does not have the capability to utilize the stimulants in the context of starvation.
-as per guest speaker
