Mental Health Flashcards
True or False: Maternal-infant bonding is important immediately after birth
True
What is more important to do in the first hour of life?
- Vitamin K
- Erythromycin
- Maternal-infant skin to skin
Skin to skin
What is the definition of colic?
Crying more then 3 hours per day, more than 3 days per week, for more than 3 weeks for no apparent reason
What causes colic?
Multi-factorial
How is colic diagnosed?
Based on history
*PE doesn’t show anything and no labs to confirm diagnosis
When does colic begin?
2 weeks
When does colic peak?
6 weeks
When does colic resolve?
4 months
How many hours a day of crying can be normal in an infant from birth-6 weeks?
Up to 2 hours
*Same for premature
How many hours of crying a day can be normal in an infant from 6-weeks and beyond?
3 hours a day
*Same for premature
Crying in an otherwise healthy infant that usually starts suddenly and occurs around the same time every day (usually evening)?
Colic
Babies who cry hard and long, draw up their legs, tense their bellies, arch their backs… seems like they are in pain?
Colic
What is management for colic?
- Support/reassurance
2. Have another caregiver take over to reduce parental frustration
When would you prescribe medication (gas drops) or change formula to treat colic?
Never (this will rarely be the correct answer)
True or False: Trying to make the environment nice and quiet actually can make colic worse
True
Infants who cry excessively are at increased risk for what?
Child abuse
2 month old who cries continuously… usually for 2 hours around 5AM and 1 hour around 1AM.. what should parents do?
Reassurance
*Add up total hours crying, only 3, this is normal
True or False: Most kids have temper tantrums at some point in their lives?
True (especially common in toddlers)
What is helpful if tantrums are caused by frustration with a task?
Redirection or distracting them before tantrum can occur
What is helpful for toddlers who have temper tantrums?
Consistent daily routine
What should parents do about temper tantrums?
- Ignore them (unless child is in danger of harming themselves)
- Let the child calm down in a safe place
- Avoid physical restraint (increases child’s frustration)
What age group are breath holding spells usually seen in?
6-18 months
Toddler who is angry, frustrated, or in pain. They cry and then become pale/cyanotic…?
Simple breath holding spell
Toddler who is angry, frustrated, or in pain. They cry and cry until they are unconscious…?
Complex breath holding spell
True or False: A breath holding spell can progress to a hypoxic seizure with a post-ictal period
True: This is still a breath holding spell, not a seizure disorder
What is management for a breath holding spell?
- Behavioral modification
2. Reassure parents it’s not harmful (so they don’g give into child’s demands to avoid them)
What is the golden rule of behavior management?
Praise a child’s desirable behaviors and ignore undesirable behaviors
What is it called when a parent or caregiver withdraws all attention from a child who is displaying undesirable behaviors?
Extinction
What is an extinction burst?
When a parent withdraws attention from a child who is displaying undesirable behaviors and the behavior initially worsens. If parent can hold out, behavior will decrease in frequency.
What hematologic problem has an association with breath holding spells?
Iron deficiency anemia
Treatment of what problem (if present) can reduce the frequency of breath holding spells?
Iron deficiency anemia
*However, anemia is not considered to be the actual cause of breath holding spells
What ages is time out best for?
Age 1 and up
How long should time-outs last?
One minute per year of the child’s age
What is time-in?
Positive feedback: Parent makes reassuring contact when child is engaging in appropriate behavior (positive reinforcement)
What is token economy?
When a child receives a token for positive behavior
What age group is token economy effective in?
3-7
What is the preferred strategy for discipline in kids with ADHD?
Token economy
What needs to be done for a neurologically-intact child between 8 months-4 years who is head-banging (especially around bed time)?
Reassurance: This is normal and doesn’t need any intervention
True or False: Head banging always indicates a sensory deficit
False- this can be a normal finding
Toddler with language delay, poor eye contact, and head banging… what is something to consider besides autism?
Neglect… watch for signs like missed appointment, ect.
Child older than 4 with headbanging and other signs/symptoms of developmental delay… is this normal?
No (outside range of normal head-banding behavior)
Up until what age is biting considered a normal behavior as a reaction to frustration?
3
What is management for biting?
- Redirect and say “No Biting” (verbal scolding- simple/neutral)
- Remove positive reinforcement
- Time-out
What is the best initial intervention for thumb sucking in a toddler?
- Redirecting so they use their thumbs for something else
2. Positive reinforcement when they aren’t thumb sucking
At what age would you consider intervention for thumb sucking?
Over 4, under this age it is likely they will outgrow it
True or False: Most thumb sucking is considered to be harmless and no intervention is needed
True
What can prolonged thumb sucking beyond age 4 lead to?
Dental problems (malocclusion)
What do you do with a pre-school or school age child who is masturbating?
Nothing- this is normal to a certain extent
*If child is imitating sexual activity, this is NOT normal
What are three things which may increase sexual self-stimulation behavior in children?
- Vulvovaginitis
- Recurrent UTI
- Use of bubble baths
What is an age-appropriate discomfort over a situation that is realistic within the context?
Fear
What is an anxiety that is excessive based on the potential danger posed (after accounting for age and developmental level)?
Phobia
How long does something need to interfere with daily function for to be considered a phobia?
6 months
What are 2 ways to manage phobias?
- Desensitization: Gradual exposure to feared object or situation
- Cognitive Behavioral Techniques: Child is shown how to re-frame situations triggering the phobia
*Meds not well-studied for this and likely not correct choice
True or False: Teen parents don’t typically stay together long
True
What can contribute to misinterpretation of age-appropriate behavior?
Unrealistic expectations
*This can result in inappropriate punishment
True or False: Involvement of a teen father is beneficial to the child
True (but is dependent on nature of relationship with Mom)
True or False: School phobia occurs more frequently when there is only 1 caretaker
True
What is the best way to deal with school phobia?
Have Mom go to school with child and wean amount of time spent there
True or False: Separation anxiety can be a normal developmental stage in pre-school children
True
What can pure truancy from school be a component of?
ODD
Teenage female who experiences chronic pains, recurrent nightmares, fears of being alone, diminished interest in school, and/or decreased appetite weeks to months after experiencing a sexual assault?
PTSD
What are the 2 core symptoms of ADD?
- Inattentiveness
2. Impulsivity
Besides inattentiveness and impulsivity, what is the third core symptoms of ADHD?
Hyperactivity
What are the requirements regarding symptoms to be diagnosed with ADD/ADHD?
- Present before age 12
- Present in 2+ settings
- Impair functioning
- Present for at least 6 months
- Not explained by another condition
Which presentation of ADHD is more common in boys?
ADHD- predominantly hyperactive
Which presentation of ADHD is more common in girls?
ADHD-inattentive
When is ADHD often diagnosed?
Upon entering school
*Usually retrospective evidence of symptoms during toddler/preschool years (sleep disturbance, behavioral problems)
What % of kids diagnosed with ADHD continue to meet criteria for diagnosis at adolescence and adulthood?
60-80%
Name 6 things that increase risk of ADHD
- Maternal tobacco use
- Maternal alcohol use
- Lead exposure
- Low birthweight
- Prematurity
- IUGR
True or False: Symptoms of ADHD can be eadily repressed in an office setting, especially at the initial visit
True
What areas of the brain are less activated in kids with ADHD when they perform executive functions (problem solving/working towards a goal)?
Areas rich in dopaminergic and noradrenergic pathways
True or False: Neurodiagnostic imaging is part of the workup for ADHD?
False
What type of seizure may present similarly to ADHD?
Absence
*Usually history can rule thus out and getting an EEG may not be right answer
“Suddenly stops speaking”, “Snaps out of it and comes to”, “Twitching of eyelids/lips”
Absence seizures
What can induce an absence seizure?
Hyperventilation
What are 4 differentials to consider for ADHD?
- Absence seizures
- Depression
- Anxiety
- Substance abuse (teens)
How can depression/anxiety mimic ADHD?
Causes inattention and/or acting out behaviors
For a teen who develops ADHD symptoms with no prior history of inattention or depression, what should you consider?
Substance abuse
Name 5 organic causes of ADHD to rule out in your workup
- Visual/hearing deficits
- Lead toxicity
- Hyper/hypo thyroidism
- Previous neuro damage (infection/trauma)
- Medications (Phenobarbital, antihistamines)
Name 3 syndromes to consider with ADHD
- Fragile X
- Fetal Alcohol
- Williams
*Will have other symptoms
History classic for ADHD, but also mentions lethargy, abdominal pain, poor appetite…?
Lead toxicity
What % of kids with ADHD may have a coexisting condition (ODD, conduct disorder, anxiety disorder, mood disorder, learning disorder, social immaturity)?
65%
What are the 2 best proven treatment modalities for ADHD?
- Pharmacological + Behavioral
2. Pharmacological alone (stimulants)
True or False: It is important to allow families to add their own methods to stand care for ADHD
True (as long as they aren’t harmful to the child)
True or False: Most complementary/alternative strategies to treat ADHD haven’t been proven effective
True (but families still seek this out)
What are the 2 families of stimulants for ADHD?
- Methylphenidate
2. Amphetamine
Which family of stimulants includes Ritalin, Methylin, Quillivant, Concerta, Metadate, and Daytrana?
Methylphenidate
Which family of stimulants includes Dexedrine and Adderall?
Amphetamine
Which patient should you take caution with in prescribing a stimulant?
- Small children
- Heart conditions
- Psychiatric conditions
- Seizures
Name 13 side effects of stimulants
- Insomnia
- Weight loss
- Anorexia
- Rash
- GI complaints
- Tachycardia
- Elevated BP
- Palpitations/arrhythmia
- Headahces
- Restlessness
- Visual disturbances
- Abnormal liver function
- Hair loss
True or False: An EKG is indicated prior to starting medication for ADHD
False
*Need to consider risk in kids with pre-existing cardiac conditions
True or False: In kids without preexisting cardiac conditions, the risk of sudden death or ventricular arrhythmia is significantly higher than in kids who aren’t taking ADHD medication
False
How do stimulants effect anxiety?
They can worsen or improve it
Which two medications can stimulants increase serum concentrations of?
- TCAs
2. Seizure meds
`What can happen if you give a stimulant in addition to an MAOI?
HTN crisis
Is improved symptoms on stimulants diagnostic of ADHD?
No- Stimulants will improve attendtion in kids/adults who don’t have ADHD
How do stimulants affect people with tic disorders?
May unmask symptoms in kids who are predisposed, but do not cause this (i.e. Tourette)
True or False: The isolated appearance of motor tics while on stimulants is usually transient
True
Are motor tics that occur once a stimulant is started a contraindication to the use of this medication?
No
True or False: Stimulants are often needed outside of school hours
True- To get homework done
*Also gives parents a chance to observe for adverse effects
Name 3 nonstimulants which can be used for ADHD
`1. Atomoxetine (Strattera)
- Clonidine (Kapvay)
- Guanfacine (Intuniv)
What category of medication is Strattera?
Non-stimulant, norepinephrine reuptake inhibitor
Name 2 alpha adrenergic agonsits used for ADHD
- Clonidine
2. Guanfacine
How much time needs to pass before you can given Atomoxetine to someone who was on an MAOI?
Need 2 weeks off of MAOI before you can give it
What 2 groups of patients do you need to extra cautious with when giving Atomoxetine?
- Cardiac conditions
2. Concurrent albuterol therapy
What do you need to monitor closely for in kids on atomoxetine (especially preteen boys)?
Suicidal thinking
Name common side effects of atomoxetine
- GI symptoms
- Poor weight gain
- Fatigue
- Dizziness
- Mood swings
- Aggression
- Severe liver injury
- Sedation
When should atomoxetine be given
At bedtime (its sedating)
What is the most important thing to distinguish in terms of diagnosing depression?
Normal variation versus true depression
Name some signs of depression
- Somatization
- Withdrawal
- Appetite change
- Falling grades
- Acting out
True or False: Adolescents can have mood swings without being depressed
True
When is depression more likely than a mood swing?
When symptoms are interfering with daily functioning and beyond limits of normal
Name 4 things which increase risk for depression in kids
- Parental depression (genetic/environmental)
- Chronic illness
- Taking glucocorticoids
- Taking immunosuppresive agents
Name 3 comorbid conditions which can presents in kids with depression
- Anxiety
- ADHD
- Substance abuse
What is the typical first-line agent for depression in children?
Fluoxetine
What category of drug is Fluoxetine?
SSRI
What other medication is contraindicated in children taking Fluoxetine?
Any MAOI
What 3 circumstances do you need to be careful when using Fluoxetine?
- Kids on diuretics
- Liver disease
- Kidney disease
Name side effects of SSRIs
- Headache
- Insomnia
- GI upset
- Weight loss
How do SSRIs increase other levels of some drugs?
It’s a CYP450 inhibitor- Concomitant drug levels may increase
What type of drug is amitriptyline?
TCA
Who are TCAs (amitriptyline) contraindicated in?
- Seizures
- Severe cardiac disorders
- MAOI in last 14 days
Can you stop amitriptyline cold turkey in someone who has been taking high doses for prolonged periods of time?
No
How is amitriptyline metabolized?
CYP 450 system
Name side effects of amitriptyline
- Sedation
- Urinary retention
- Constipation
- Dry mouth
- Dizziness
- Drowsiness
- Liver enzyme elevation
- Arrhythmia
What needs to be monitored when starting amitriptyline and with dose changes?
- EKG
- BP
- CBC
What medication used for depression can cause blue/green urine?
Amityriptyline
What is the most effective psychotherapeutic treatment for depression in kids and adolescents?
CBT
What type of medications is phenelzine, tranylcypromine, isocarboxazid, moclobemide, pargyline, procarbazine, and selegiline?
MAOIs
What is the black box warning for most antidepressants in kids?
Worsen depression and increase risk of suicidaity- Need careful monitoring when anything is started or dosage changed
What do you need to consider if mania is noted after starting an antidepressant?
Bipolar- Stop medication immediately
What is the only FDA-approved medications for the treatment of depression in Kids and adolescents?
Fluoxetine
What are 3 potential anti-depressants commonly used in kids?
Fluoxetine, citalopram, sertaline
What type of effect can suicide in a community have?
Domino- Amount of media attention thought to have a role in increasing risk
How do you screen for SI?
Ask a depressed teen about suicidal thoughts (this doesn’t put the idea in their head)
When is it okay to dismiss a suicidal gesture that seems to be superficial?
Never
What type of suicidal gesture is especially concerning?
One that is undertaken alone with no rescue available
Name 9 risk factors for suicide
- Substance abuse
- Loss of a loved one
- Family discord
- Social isolation
- Availability of firearms
- Previous suicide attempt
- Family history of suicide
- Native American teens and Hispanic females
- Underlying mood/anxiety disorders
Which gender engages in self harming behavior more often?
Females
Which gender is more likely to commit suicide?
Males
Child who is negativistic, defiant, disobedient, hostile, refuses to do what they are told, little respect for authority?
ODD
How can you distinguish ADD v. ODD in terms of following rules?
ADD can’t, ODD won’t
Kid who has had problems with lying, stealing, setting fires, cruelty to animals. Does things that impinge on basic rights of others or violate major age-appropriate social rules?
Conduct disorder
How long do symptoms need to be present to diagnose conduct disorder?
At least 6 motnhs
How are ODD or conduct disorder managed?
Team approach: Manage comorbid conditions (ADHD/depression), entire family in bheavior centered therapy, structured parent training programs
Intensely driven, seemingly pointless repetitive behaviors along with recurrent thoughts and worries?
OCD
What are seemingly pointless repetitive behaviors?
Compulsions
What are recurrent thoughts and worries?
Obsessions
What is OCD a form of?
Anxiety
What relives the anxiety in OCD?
Behaviors (carrying out compulsions)
What causes OCD?
Genetic + Environmental
some think immunoreactive due to infection in susceptible individual
What are 2 characteristics of psychotic disorders?
- Hallucinations
2. Delusions
What is a hallucination?
Seeing/hearing things that aren’t there
What is a delusion?
Belief a person holds as true despite absence of proof (being watched by aliens/having superpowers)
Name a psychotic disorder than can begin in childhood?
Schizophrenia
What is the main component of treatment for psychotic disorders like schizophrenia?
Anti-psychotic medications
*Also need support/counseling- Will often stop meds once feel well because they think symptoms won’t return
What is PANDAS?
Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infection
What is once condition which may be a manifestation of PANDAS?
OCD
What % of uses does cannabis cause a transient psychotic state?
10-15%
What can be the initial presentation of Bipolar Disorder?
Major depressive episode
What should you think for a kid who is depressed, starts an antidepressant, and becomes manic?
Bipolar
What are the symptoms of mania?
- Disruptive behavior
- Decreased need for sleep
- Racing thoughts
- Elation
- Hypersexual behavior
- Grandiose thinking
What comorbid conditions to patients with Bipolar disorder have a high rate of?
ADHD, psychiatric disorders (anxiety, conduct disorder, substance abuse, ODD)
What type of behavior is aggression?
Disruptive
Name some aggressive behaviors
- Temper tantrums
- Hitting
- Biting
- Stealing
- Defiance of authority
When are aggressive behaviors considered a psychiatric disorder?
- Form a pattern over time
- Inappropriate for age
*If temporary can be considered normal
Name 5 risk factors for aggressive behaviors
- Neglect
- Psychological maltreatment (destroys child’s sense of self and personal safety)
- Family history of aggressive behavior (incarceration, use of physical discipline)
- Exposure to violence in media (movies/video games)
- Lead poisoning
What are the 2 most effective treatments for aggressive behavior?
- Parent management training (positive reinforcement)
2. Cognitive behavior therapy
What do you need to assess for and treat when delaing with aggressive behavior?
Comorbid conditions: ADHD, depression, mood disorder, anxiety (may need medications)
What is the biggest predictor of developing bipolar disorder?
Family history
What is felt to cause bipolar disorder?
Genetic + Environmental: Genetically susceptible kids being raised in dysfunctional home + emotional trauma time time of critical CNS maturation
What can precede the onset of bipolar disorder?
Years of anxiety, sleep disorders, mood disturbances, adjustment issues
