Mental Health and Development Flashcards
Updated 01/04/2024
Which of the following ADHD medications are amphetamines?
- Concerta
- Biphentin
- Intuniv
- Dexedrine
- Adderall
- Ritalin
- Vyvanse
- Strattera
Amphetamine Class Stimulants
Available in Short (3 y+) and Extended Release (6 y+) formats
- Adderall; lasts 6 - 8 h (capsule than can be opened then given)
- Vyvanse; lasts 8 - 13 h (capsule than can be opened then given)
- Dexedrine; lasts 4 - 6 h (capsule that muse be swallowed whole)
What are the 5 points of Longitudinal ASD management that the CPS endorses ?
Longitudinal Pediatric Management of ASD
-
Assess for comorbidities
- Genetics following, Hearing and Vision testing
- Dental/Nutritional deficits (picky eater, stereotypes sequelae)
- Anxiety, Mood, Psychotic and attention disorders (CBT and SSRIs ok!)
- Routinely ask about parents’ complementary therapies
- Be up to date with the impact/efficacy of cannabis
- Are they using specialised diets?
- Re-assess access to community resources (needs change)
- Re-evaluation by SLP/OT/PT/Nutrition ?
- Do the parents/siblings need new practical or mental health supports
- Appraise Sleep Hygiene
- Assess aggression management
- Behavioural therapy and psychiatric comorbidity assessment first always
- Consider aripiprazole or risperidone (poor evidence)
EPI BULLETS
- 1/20 children wordwide have ADHD
- 11 % of adolsecents/young adults sell their Rx stimulants
- 22 % of adolescents misuse their Rx stimulants for recreational highs or hyperfocused states
- ~ 50 % of adolescents admit to not taking their IR stimulant
- IR is more implicated than XR for adverse uses/vending
IR = immediate release, XR = extended release, Rx = prescribed
Justify the following investigations regarding GDD or ID
- Chromosomal Microarray and Fragile X Testing
- Brain MRI
- Head CT
- Electroencephalogram (EEG)
- Serum Lead Levels
- TSH / T4
- Genetics Referral
- Neurology Referral
- CBC and differential
Global Developmental Delay and Intellectual Defeciency
No shotgun approaches. If you have probable cause don’t look for more.
- Chromosomal Microarray and Fragile X Testing
- If there is no obvious diagnosis on H/P (e.g. neonatal stroke)
- Brain MRI
- If brain-relevant genetic syndrome is suspected
- If abnormal EEG or focal neurologic findings
- History suggestive of neonatal asphyxia/stroke
- Head CT - Never
- Electroencephalogram (EEG) - If there are seizures
- Serum Lead Levels - If H/P suggests anemia/lead poisoning
- TSH / T4 - Routine; repeat if growth issues/consistent H/P
- Genetics Referral - Positive uarray or relevant work-up has no yield
- Neurology Referral - Seizures or relevant work-up has no yield
- CBC and differential - Suspected anemia from H/P
Describe the sequence of events for Return to Play, for a child post-concussion
Return-to-Play Protocol
- Cognitive Rest until symptoms are ok (limit screens, no school)
- Increase cognitive activities by 15-20 min per day
- Return to school gradually (1-2 classes, half-days, no tests)
- Limit symptom triggering classes (Shop, Gym, Music class)
- Allow 1 test per day, in optimized setting (isolated, quiet, well lit)
- Only once symptom-free with FULL school activities can you return to play.
Throughout this process check for _mood/anxiety disorders_ developments as limiting high achievers predisposes these developments
Define the following sleep terms:
- Sleep Latency
- Sleep duration
- Waking Events
Latency - the delay from when the patient assumes the “in bed” position and when they fall asleep. This is a key measurement for assessing Delayed Sleep Phase disorders. Normally ~ 30 minutes
Duration - sum of time a patient sleeps in the night
Waking Events - number of times a patient awakes in the evening and has to repeat the sequence of falling asleep.
What 5 Principles of Circumstance does the CPS enforce to include in discussions about Parenting?
5 Principles of Family Circumstance
- Help build meaningful/interactive loving relationships
- Stable Home Infrastructure is essential for positive behaviour building, and poor behaviours do happen.
- Identify risk factors for Adverse Childhood Experiences (e.g. crime in home, drugs, parental risky behaviours, poverty)
- Recognise cultural differences in parenting (no physical abuse though)
- Have resources for healthy parenting on hand if issues arise
What is Behavioural Insomnia of Childhood, and how can it be treated?
Insomnia secondary to developmentally abnormal practices adopted by the patient/family that must be met for a child to fall asleep.
Consistent boundaries instilled by parents regarding bedtime rules and conditions have the best evidence for cutting bad habits.
There will be tantrums.
List 2 negative aspects of Immediate Release Stimulants and 2 positive aspects of Extender Release Simulatants, as treatments
(as endorsed by the CPS)
-
Immediate Release
- Requires a repeated dose at school
- Social stigma with “taking a pill”
- Low compliance
- Associated with misuse/vending
-
Extended Release
- Does not require school-involved with medication
- Better compliance
- Improved durations of treatment
- Associated with fewer hospital presentations for impulsivity related medical concerns
TRUE or FALSE
Children and Adolescents who have been concussed should not be permitted to fall asleep
FALSE
This is a common urban medical myth.
Sleep is essential to the recovery of a patient with a concussion, however within the first 24 - 48 h, depending on the mechanism, there can be a concern for deterioration.
Children should be checked on, but not woken, if concerned for possible deterioration.
TRUE or FALSE
Non-stimulant medications for ADHD have similar efficacy and can be used as a first line therapy
FALSE
Non-stimulant therapies for ADHD have not been shown to be as effective as stimulants for impulsivity, aggression, inattention or functioning. They are first line for isolated ADHD, ADHD + ID and ADHD + ID unless there’s a contraindication to stimulant therapy
Contraindications to first-line stimulant therapy include worrisome history of substance abuse and known cardiac disease (structural or electrical).
Give a genetic risk factor for Autism Spectrum Disorder
(3 listed by CPS)
ASD Genetic Risk Factors
- Male sex
- First degree relative with ASD (also increased with any Fhx)
- Genetic Disorders including (but not restricted to)
22q11.2 Spectrum disorders, 15q chromosomal anomalie, Neurofibromatosis - 1 (NF-1), Trisomy 21, Tuberous sclerosis, Fragile X Syndrome, Angelmann Syndrome, Rhett Syndrome, Noonan Syndrome, Williams-Beuren Syndrome.
What are the indications for Short Term stimulant use in ADHD ?
First line therapy for ADHD typically is Long Term Stimulants
Short Term Formulations can be used for:
- Short Term Goals (e.g. afternoon/morning-only symptoms)
- Children younger than 6 years old
EPI BULLETS
- Worldwide incidence of ADHD is 3.4 %
- 50 % of childhood onset ADHD persists to adulthood
- 90 % of children with ODD/CD have ADHD symptoms
- Children with ASD have a 50 % risk for having comorbid ADHD
- Untreated ADHD is associated with:
- Risky behaviours (cigarettes, marijuana, illicit drugs, unprotected sex)
- Low education potential attainment
- Accidents (Motor vehicle and general trauma)
- Mortality
Which of the following ADHD medications are methylphenidates ?
- Concerta
- Biphentin
- Intuniv
- Dexedrine
- Adderall
- Ritalin
- Vyvanse
- Strattera
Methylphenidate Class Psychostimulants
- Concerta; 8 - 12h (capsule that must be taken whole)
- Biphentin; 6 - 10h (capsule that can be opened and swallowed)
- Generic Biphentin; 6 - 10h (capsule that can be opened and swallowed)
- Ritalin; 4 - 5h (tablet that must be swallowed whole)
Give Post-Natal Risk Factors for Autism Spectrum Disorder
(CPS gives 2)
Post-Natal Risk Factors for ASD
- Low birth weight
- Extreme Prematurity
Although not in the ASD CPS Statements, consider in any genetic syndrome with ID/Developmental issues as per other CPS statements
What are signs concerning for ASD between 15 - 24 months?
What do you do about it
ASD Diagnosis in 15 - 24 months
- No single words +/- compensatory non-verbal/grunting
- No experience sharing
- No imaginative play
- No 2 word combination (echolalia can mimic combinations)
Management
- Assess hearing and vision
- Screening metabolic and genetic bloodwork
- History for Risk Factors for Autism (Peri-natal, Fhx, exposures)
- Referral to Developmental Pediatrics/Multidisciplinary Eval.
- Follow-up monthly
TRUE or FALSE
Between 2 years and School Age, there is enough variability in development that you can allow some deficits. They will normalise those once they enter Pre-K/Kindergarten
FALSE
This is a key point in development where possible cognitive, vision, hearing or social deficits can go missed. If these children enter school behind, they are likely to never catch-up
What is a government Early Development Instrument (EDI) ?
Early Development Instrument (EDI)
- Provincial Government endorsed (and funded) project
- Provides pre-school educators and teachers a developmental checklist to identify delays/deficits
- Currently done at 18months, Kindergarten and Grade 4
- The 5 domains of assessment include
- Physical capacity (gross and fine motor)
- Socialization
- Emotional
- Language/communication
- Cognition
EPI BULLETS
- Canadian ASD Prevalence is 1 / 66 people between 5 - 17 y.o.
- There is a 7 - 19 % sibling recurrence of ASD
- ASD patients are at risk for psychiatric comorbidities
- About 50 % suffer from anxiety disorders
- Mood disorders are common in adolescents and adults
- Psychotic disorders are also common
- 30 - 50 % has concomitant ADHD
Is Melatonin safe to use in patients with Autism, for sleep ?
YES
67 % of ASD patients have a sleep disorder. Melatonin was shown to improve Sleep Latency (2.6 to 1.06 h), Sleep Duration (8 - 9.8 h) and Waking Events (0.35 - 0.08/night average). Only 1 % of patients in a massive study had worsened sleep conditions secondary to melatonin, and no adverse reactions beyond abdominal cramping/nausea were noted beyond 1 week of therapy initiation in all studies.
Do all children need an ECG before starting psychostimulants?
NOPE
No evidence supports asymptomatic children getting an ECG.
As a pediatrician, if you find a family or personal history concerning for sudden cardiac death/structural heart disease, you obtain and ECG for THAT and refer to Cardio.
Only delay stimulant therapy for those with arrhythmia
Give 2 standardised ASD Diagnostic Tools
(Referring to Developmental Peds isn’t a tool)
- ASQ-3; for school/parents/pediatricians to help Dx
- CSBS; for parents/pediatricians to help Dx
- PEDS; for parents to help Dx
- STAT-3; for school/parents/pediatricians to help Dx
-
ADOS-2; for complex/subtle cases and grading
- Requires specialised training
- Expensive in private, long wait time in public
- CARS-2; for grading ASD features for services
- Requires a psychologist/OT to perform it ($$$)
- ADI-R; for separating ASD from comorbidities, grading
- Requires a psychologist/OT to perform it ($$$)
https://autismcanada.org/about-autism/diagnosis/screening-tools/ has everything available to you and is a good cop-out if you blank in an OSCE - you can access the right test for age here
EPI BULLETS
- 15 to 25 % of kids have sleep initiation issues
- 67 % of kiddos with Autism have sleep issues
What is the procedure for diagnosing Autism in a patient with
- Obvious Autism
- Questionable Autistic features
- Subtle autistic features in a complex neuropsychiatric context
Obvious Autism
- Can apply diagnosis with pediatric evaluation
- May reinforce with standardized testing*
- This may not be enough for ASD Services
Uncertain or Mild or Atypical Autistic features
- Standardized testing*
- If evident from testing, can diagnose in clinic
- Consider referral to Developmental/Psychiatric Peds
Complex neurologic/psychiatric comorbidities
- Refer to multidisciplianry ASD Diagnostic Team
All developmental concerns require a STACER-level complete H/P. Hearing and vision testing must also be done before ASD can be diagnosed. *Tests include ADOS-2 (needs training/certification), CARS-2, ADI-R, 3di, DISCO etc.
What is a good assessment tool for anxiety in children and adolescence ?
Screen for Child Anxiety Related Disorders (SCARED)
https://cps.ca/en/documents/position/anxiety-in-children-and-youth-diagnosis
How do you differentiate normal developmental ‘nervouseness’ vs. an anxiety disorder ?
The CPS gives the attached table which highlights the key components of the behaviours that make the characteristically due to anxiety
* Persistence (Recurrent behaviour or lingering concern)
* Impacting functioning (e.g. schoolwork, play, socialisation)
* Somatization (e.g. excessive palpitations, syncope, catatonia)
https://cps.ca/en/documents/position/anxiety-in-children-and-youth-diagnosis
Give 3 “Positive Parenting Tips” from the CPS for managing Anxiety
Parenting Tips for Anxious (and all) Children
2. Identify and name feelings
2. Avoid avoidance of discussing feelings
3. Validate fears but do not reinforce (e.g. “this is scary, but you can do it!”)
4. Engage in child-led activities // stay connected/aware of adolescent interest and activities
5. Foster self-confidence (i.e. language that is focused on them)
6. Encourage opinions and smart choices
7. Break challenges into smaller, manageable pieces, and praise after each victory
8. Reward attempts/approximations rather than fixating on results
9. Model coping techniques
10. Connect with the school in case issues arise
11. Have prepared, consistent, smooth routines for school/summer camp
12. Model positive ways of handling conflict
https://cps.ca/en/documents/position/anxiety-in-children-and-youth-management
What are the steps for managing anxiety in a child/adolescent ?
Managing Anxiety
1. Psychoeducation (e.g. pamphlets, PPP Parenting)
2. Psychotherapy (CBT has an OR of 5.45 for anxiety remission)
3. Pharmacotherapy
* SSRI and SNRI for ages 6-18 years
* Re-assess tolerance, dose and response every 2 weeks
* Avoid Paroxetine
4. School Outreach
(Establish an IEP and re-evaluate as symptoms improve)
https://cps.ca/en/documents/position/anxiety-in-children-and-youth-management
