Mental Health Flashcards
what are 3 postpartum psychiatric conditions
- postpartum blues
- postpartum depression (symptoms for at least 1 month)
- postpartum psychosis (begins within 4 weeks)
are antidepressants teratogenic?
No!!
what are some consequences of maternal depression infant toddler school aged adolescent
infant- anger
lower cognitive performance
toddler- Less creative play and lower cognitive performance
poor self control, lower interaction, passive noncompliance
school aged- Internalizing and externalizing problems, impaired adaptive functioning, anxiety, conduct disorders
ADHD, lower IQ
adolescent- depression, anxiety, panic disorders, conduct disorders, substance use
ADHD, learning disabilities
what screening questions would you ask to assess for cardiac risk factors for sudden death among children starting stimulant medication
Personal History:
SOB with exercise without explanation (asthma)
Poor exercise tolerance without other explanation
Fainting/Seizures with exercise, or fright
Palpitations with exercise
Personal or Fam Hx of: sudden death FamHx non-ischemic heart disease FamHx/Personal Hx Long QT or arrythmia WPW Cardiomyopathy Heart transplant Pulm HTN Defibrillator
Exam:
Hypertension
Murmur
Sternotomy incision
what is one of the strongest predictors of suicide during adolescence, and lifelong
A previous suicide attempt is one of the strongest predictors of suicide during adolescence, and lifelong
what risk factors are associated with increased risk of suicide?
Mental illness Prior self-harm or suicide attempt Impulsivity Precipitating factors Family factors (family conflict) Lack of psychosocial support
what should you ask on history to screen for risk of sudden cardiac death prior to starting stimulant medication
SOB on exercise without explanation
exercise intolerance
palpitations brought on by exercise
fainting/seizures with exercise
FHx of personal hx of: long QT, arrhythmias nonischemic heart disease WPW Cardiomyopathy Pulmonary HTN Heart transplant sudden unexplained death unexplained MVAs or drownings Defibillator
what should you look for on physical exam to screen for risk of sudden cardiac death prior to starting stimulant medication (3)
sternotomy scar
HTN
organic murmur
other abnormal cardiac findings
effects of divorce for age:
<3
4-5
school age
less than 3: may reflect a caregiver’s distress and grief
age 4-5: blame themselves and become clingy with separation anxiety
School age: may take sides and have loyalty conflicts
family protective factors for divorce (8)
Protection from conflict between parents Cooperative parenting Healthy relationships between child and parents Parents’ psychological well being Quality, authoritative parenting Household structure and stability Supportive sibling relationships and extended family relationships Economic stability
family risk factors for divorce (8)
Ongoing conflict between parents Poor parenting Lack of monitoring children’s activities Multiple family transitions Parent mental health problems Chaotic, unstable household Impaired parent-child relationships Economic decline
what are the 3 main processes that have a positive mediating effect on child well-being after parental divorce
improving the quality of parenting
improving the quality of parent–child relationships controlling hostile conflict
are routine labs required before starting an SSRI?
No routine Labs needed prior to starting (unless screening for thyroid as cause of sx, liver disease if concerning symptoms, or monitoring other drug levels that may interact, like valproic acid
After starting an SSRI in a child what monitoring is required?
1) weekly for the first four weeks after initiation of SSRI
2) every two weeks for the next four weeks;
3) at 12 weeks;
4) as clinically indicated beyond the 12-week point
Once a complete response has been achieved with SSRI, how long should the medication be continued?
should be continued for a minimum of six to 12 months to decrease the risk of depressive relapse
Which SSRI medication has the most data supporting its use for treating depression in children and adolescents?
Fluoxetine
What is the max dose for citalopram
Citalopram should not be used in dosages >40 mg/day.
what children should not be prescribed citalopram
should not be prescribed for children and adolescents with congenital long QT syndrome.
what could you tell parents about the risk of SI with starting an SSRI
The risk of suicidality associated with untreated depression is likely greater than that associated with appropriate SSRI use.
To improve tolerability of medication for anxious patients, clinicians should include the following in their overall approach: (3)
To improve tolerability of medication for anxious patients, clinicians should include the following in their overall approach:
Psychoeducation
Lower starting dosages
Gradual titration to therapeutic dosages.
what is the half life and dosing schedule for fluoxetine
96h, dosed daily
what are some common short term side effects of SSRI’s
gastrointestinal symptoms sleep changes (either insomnia or somnolence, and sleep disturbances, including vivid dreams) restlessness headaches appetite changes sexual dysfunction
A cluster of disruptive behaviours is considered to be at the disorder level when the following criteria are met:
Behaviours are atypical for the child’s developmental age and persist for 6 months or more,
Behaviours occur across situations, and result in impaired functioning, and/or
Behaviours cause significant distress for both child and family
what are 3 factors associated with atypical child tantrums
- frequency (daily or repeated clusters)
- intensity (associated with aggressive behaviours)
- duration (eg >5min)
What is the first-line intervention for children with significant disruptive behaviours?
Consider evidence-based parent-training programs as a first-line intervention for children with significant disruptive behaviours.
what is the diagnostic criteria for global developmental delay (Table)
Significant delay (at least 2 SDs below the mean with standardized tests) in at least two developmental domains from the following: Gross or fine motor Speech/language Cognition Social/personal Activities of daily living Reserved for children <5 years old
what are the diagnostic criteria for intellectual disability
Intellectual disability (intellectual developmental disorder)*:
The following three criteria must be met:
Deficits in intellectual functions, such as reasoning, problem-solving, planning, abstract thinking, judgment, academic learning and learning from experience, confirmed by both clinical assessment and individualized, standardized intelligence testing.
Deficits in adaptive functioning that result in failure to meet developmental and socio-cultural standards for personal independence and social responsibility. Without ongoing support, the adaptive deficits limit functioning in one or more activities of daily life, such as communication, social participation and independent living, across multiple environments, such as home, school, work and community.
Onset of intellectual and adaptive deficits during the developmental period.
what are the 4 broad categories for causes of global developmental delay
prenatal intrinsic- genetic, metabolic
prenatal extrinsic- toxins/teratogens, infections
perinatal- asphyxia, prematurity
postnatal- neglect, infections, toxins, trauma
55% from perinatal
what are the initial investigations for GDD
- History and physical
- Audiology
- Ophthalmology
- EEG if seizures
- refer to rehabilitation services while awaiting results
If GDD is suspected after history/physical and no known cause then what investigations should be done
- chromosomal microarray
- Fragile x- testing
- Tier 1 testing
- Brain MRI if abnormal neurological exam, seizures, macrocephaly or microcephaly
- Consider MECP2 in girls with Mod-Severe GDD
If a diagnosis of GDD is not found after microarray and fragile x testing what is the next step
- Brain MRI
- Genetics/Metabolics referral- Tier 2 testing, gene panels
- Consider referral to neurology
what are the Tier 1 investigations for GDD
Complete blood count
Glucose
Blood gas
Urea, creatinine
Electrolytes (to calculate anion gap)
AST, ALT
TSH
Creatine kinase
Ammonia
Lactate
Amino acids
Acylcarnitine profile, carnitine (free and total)
Homocysteine
Copper, ceruloplasmin** - not by recommended AAP but in TIDE protocol
Biotinidase*** - clinica expert recommendation only
Ferritin, vitamin B12 when dietary restriction or pica are present
Lead level when risk factors for exposure are present
what are first-line investigations for children with unexplained GDD/ID.
Chromosomal microarray and Fragile X DNA testing
what are some red flags suggestive of inborn errors of metabolism (table)
Family history of IEM or developmental disorder or unexplained neonatal or sudden infant death
Consanguinity
Intrauterine growth retardation
Failure to thrive
Head circumference or stature growth abnormality (>2 SD above or under the mean)
Recurrent episodes of vomiting, ataxia, seizures, lethargy, coma
History of being severely symptomatic and needing longer to recover with benign illnesses (e.g., upper respiratory tract infection)
Unusual dietary preferences (e.g., protein or carbohydrate aversion)
Regression in developmental milestones
Behavioural or psychiatric problems (e.g., psychosis at a young age)
Movement disorder (e.g., dystonia)
Facial dysmorphism (e.g., coarse facial features)
Organomegaly
Severe hypotonia
Congenital nonfacial anomalies
Sensory deficits, especially if progressive (e.g., cataracts, retinopathy)
Noncongenital progressive spine deformities
Neuro-imaging abnormalities
what % of children with ADHD will continue to have symptoms in adulthood
50%
what conditions are often co-morbid with ADHD (similar list for conditions misdiagnosed as ADHD)
ODD and CD- as high as 90% with ADHD Anxiety- 30% Mood disorder- depressive symptoms, bipolar disorder substance use disorder Tic disorder Developmental coordination disorder (DCD) ASD Specific learning disorder Eating disorders (Especially females)
what are the 3 types of ADHD
predominantly inattention presentation predominantly hyperactive-implusive presentation combined type (criteria are met for inattention and hyperactive)
symptoms for ADHD must present before what age and persist for how long
before age 12 and persist >6 months
what are the criteria for ADHD hyperactivity
fidgets leaves seat runs/climbs no quiet play on the go/motor talks excessively blurts not wait turn interrupts/intrudes
what are the criteria for ADHD inattention
close attention/mistakes sustaining attention not listen not follow through poor organization sustained mental effort lose things easily distracted forgetful
what is ADHD
Persistent pattern of hyperactivity-impulsivity and/or inattention that interferes with functioning or development and negatively impacts social/academic/occupation
what is the first line treatment for children < 6 yoa with ADHD
Parent Behaviour Training
what is first line treatment for ADHD >6 yo
extended release stimulant either methylphenidate class or amphetamine class
what can happen if you stop Intuniv suddenly
rebound hypertension and tachycardia
what are 2 non-stimulant treatments for ADHD
Straterra (Atomoxetine)-norepinephrine reuptake inhibitor
Intuniv (Guanfacine XR)- alpha 2 agonist
what are the non pharmacological interventions for ADHD
*table!!
psychoeducation shared decision making parent behavior training classroom management daily report card behaviour peer interventions diet exercise
others: social skills training, organizational skills training, cognitive training, EEG neurofeedback
what are 3 groups that are at increased risk of ADHD
ID
prematurity
ASD
what are risk factors for persistence of ADHD into adulthood
combined inattention/hyperactivity
increased symptom severity
comorbid major depressive or other mood disorder
high comorbidity (>3 additional DSM disorders)
parental anxiety
parental antisocial personality disorder
what is the most common adverse effect of stimulations medications in patients with ADHD and Autism
irritability and emotional outbursts
an IQ above what level predicts a better response to stimulants
an IQ above 50 predicts a better response to stimulants
what is ‘preterm behavioural phenotype’
difficult-to-manage behaviours relate to symptoms associated with ADHD: inattention, internalizing disorders (anxiety, depression, withdrawal, somatic complaints), and social difficulties
Disruptive behaviour disorders, such as oppositional defiant disorder, conduct disorder, and hyperactive/impulsive presentation in ADHD, are seen less frequently
