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Pediatric Psych Flashcards

1
Q

Pathogenesis of ADHD

A
  1. A genetic imbalance of catecholamine metabolism in the cerebral cortex appears to play a primary role

Various environmental factors may play a secondary role
controversial

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2
Q

Cerebral structural and functional abnormalities in what regions for ADHD? 2

These abnormalities result in what?
2

A
  1. prefrontal structures
  2. basal ganglia regions
  3. Impaired executive functions (processes involved in forward planning, including abstract reasoning, mental flexibility, working memory)
  4. Impulsivity
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3
Q

Dietary influences on ADHD
Areas of investigation include:
5

A
  1. Food additives (artificial colors, artificial flavors, preservatives)
  2. Refined sugar intake
  3. Food sensitivity (allergy or intolerance)
  4. Essential fatty acid deficiency
  5. Iron and zinc deficiency
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4
Q

Associations with ADHD

5

A
  1. Prenatal exposure to tobacco
  2. Prematurity and low birth weight
  3. Prenatal exposure to alcohol
  4. Head trauma in young children
  5. Maternal acetaminophen use ?
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5
Q

To meet criteria for ADHD symptoms must :

6

A
  1. Be present in more than one setting (eg, school and home)
  2. Persist for at least six months
  3. Be present before the age of 12 years
  4. Impair function in academic, social, or occupational activities
  5. Be excessive for the developmental level of the child
  6. Not be caused by other mental disorders
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6
Q

Two categories of core symptoms

2

A
  1. Hyperactivity/impulsivity
  2. Inattention

Each of the core symptoms of ADHD has its own pattern and course of development.

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7
Q

Symptoms of hyperactivity may include:

5

A
  1. Excessive fidgetiness (eg, tapping the hands or feet, squirming in seat)
  2. Difficulty remaining seated when sitting is required (eg, at school, work, etc)
  3. Feelings of restlessness (in adolescents) or inappropriate running around or climbing in younger children
  4. Difficulty playing quietly
  5. Difficult to keep up with, seeming to always be “on the go”
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8
Q

Symptoms of impulsivity include:

4

A
  1. Excessive talking
  2. Difficulty waiting turns
  3. Blurting out answers too quickly
  4. Interruption or intrusion of others
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9
Q

Hyperactive and impulsive symptoms
1. Hyperactive symptoms are typically observed by the time the child reaches what age?

  1. Increase during the next three to four years, peaking in severity when the child is ____ years old
  2. At what age do the hyperactive symptoms begin to decline?
  3. Impulsive symptoms usually persist for how long?
A
  1. 4 years old
  2. 7-8
  3. over 8
    by the adolescent years symptoms may not be noticeable to others although may feel restless or unable to settle down
  4. throughout life
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10
Q

Symptoms of inattention

9

A
  1. Failure to provide close attention to detail, careless mistakes
  2. Difficulty maintaining attention in play, school, or home activities
  3. Seems not to listen, even when directly addressed
  4. Fails to follow through (eg, homework, chores, etc)
  5. Difficulty organizing tasks, activities, and belongings
  6. Avoids tasks that require consistent mental effort
  7. Loses objects required for tasks or activities (eg, school books, sports equipment, etc)
  8. Easily distracted by irrelevant stimuli
  9. Forgetfulness in routine activities (eg, homework, chores, etc)
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11
Q

Inattentive subtype:
1. Children with the inattentive subtype often are described as?

  1. Typical presenting complaints center on what kind of problems?
  2. Symptoms of inattention typically are not apparent until the child is what age and last how long?
A
  1. having a sluggish cognitive tempo and frequently appear to be daydreaming or “off task“.
  2. cognitive and/or academic problems.
  3. 8-9 years of age and usually are a lifelong problem
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12
Q

Symptoms may impair function in 3 areas

A
  1. Academic
  2. Social
    - -Social skills in children with ADHD often are significantly impaired
  3. Occupational
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13
Q

Evaluation

4

A
  1. Medical
  2. Developmental
  3. Educational
  4. Psychosocial evaluation
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14
Q

Medical evaluation : Interview of the parents

A
  1. How is your child doing at school?
  2. Have you or the teacher noticed any problems with learning?
  3. Is your child happy in school?
  4. Does your child have any behavioral problems at school or home, or when playing with friends?
  5. Does your child have problems completing school assignments at school or home?
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15
Q

Medical evaluation: History

7

A
  1. Prenatal exposures (eg, tobacco, drugs, alcohol)
  2. Perinatal complications or infections
  3. Central nervous system infection
  4. Head trauma
  5. Recurrent otitis media
  6. Medications
  7. Family history of similar behaviors is important because ADHD has a strong genetic component
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16
Q

PE

4

A
  1. Measurement of height, weight, head circumference, and vital signs
  2. Assessment of dysmorphic features and neurocutaneous abnormalities
  3. A complete neurologic examination, including assessment of vision and hearing
  4. Observation of the child’s behavior in the office setting
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17
Q

Developmental and behavioral assessment includes

6

A
  1. Specific information about the onset, course, and functional impact of ADHD symptoms
  2. Emotional, medical, and developmental events that may provide an alternative explanation for the symptoms
  3. Developmental milestones, particularly language milestones
  4. School absences
  5. Psychosocial stressors
  6. Observation of parent-child interactions
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18
Q

Behavior rating scales

What are the two types?

A
  1. ADHD specific scales (narrow band scales)

2. Broadband scales assess a variety of symptoms

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19
Q

ADHD specific scales (narrow band scales) are used for what?

A

Can be used to establish the presence of the core symptoms of ADHD.

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20
Q

Broadband scales assess a variety of symptoms

2 categories

A
  1. Internalizing behaviors (eg, feeling depressed, anxious, withdrawn)
  2. Externalizing behaviors other than ADHD (eg, aggression).
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21
Q

Broadband scales (with the exception of the Conners’ Long form) are not recommended for what?

What should they be used for?

A

to establish the presence of the core symptoms of ADHD

less sensitive and specific (

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22
Q

Educational evaluation

4

A
  1. Child’s teacher to complete an ADHD-specific rating scale
  2. A narrative summary of classroom behavior and interventions, learning patterns, and functional impairment
  3. Copies of report cards and samples of schoolwork
  4. Review of school-based multidisciplinary evaluations (if such evaluations have been performed)
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23
Q

Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-5) criteria: the DSM-5 diagnosis of ADHD requires what? 3

A
  1. ≥6 symptoms of hyperactivity and impulsivity
  2. or ≥6 symptoms of inattention
  3. For adolescents ≥17 years and adults, ≥5 symptoms of hyperactivity and impulsivity or ≥5 symptoms of inattention are required
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24
Q

DSM-5 criteria
The symptoms of hyperactivity/impulsivity or inattention must:
6

A
  1. Occur often
  2. Be present in more than one setting (eg, school and home)
  3. Persist for at least six months
  4. Be present before the age of 12 years
  5. Impair function in academic, social, or occupational activities
  6. Be excessive for the developmental level of the child
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25
Q

3 ADHD subtypes

  1. Predominantly inattentive? 2
  2. Predominantly hyperactive-impulsive? 2
  3. Combined? 2
A
  1. Predominantly inattentive
    - ≥6 symptoms of inattention for children less than 17 years
    - ≥5 symptoms for adolescents ≥17 years and adults
  2. Predominantly hyperactive-impulsive
    - ≥6 symptoms of hyperactivity-impulsivity for children less than 17 years
    - ≥5 symptoms for adolescents ≥17 years

Combined

  • ≥6 symptoms of inattention and ≥6 symptoms of hyperactivity-impulsivity for children less than 17 years
  • ≥5 symptoms in each category for adolescents ≥17 years and adults
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26
Q

Treatment
areas?
4

A
  1. Behavioral interventions
  2. Medication
  3. school-based interventions
  4. psychological interventions alone or in combination
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27
Q

Treatment goals.
Examples of target outcomes include improved?
3

A
  1. relationships with parents, teachers, siblings, or peers (eg, plays without fighting at recess)
  2. academic performance (eg, completes academic assignments)
  3. rule following (eg, does not talk back to the teacher)
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28
Q

Indications for referral 3

A
  1. Coexisting psychiatric conditions (eg, oppositional defiant disorder, conduct disorder, substance abuse, emotional problems)
  2. Coexisting neurologic, or medical conditions (eg, seizures, tics, autism spectrum disorder, sleep disorder)
  3. Lack of response to a controlled trial of stimulant therapy or atomoxetine
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29
Q

Who you refer to

5

A
  1. Developmental behavioral pediatrician
  2. Child neurologist (if comorbid neurological conditions)
  3. Psychopharmacologist
  4. Child psychiatrist
  5. Clinical child psychologist
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30
Q

Criteria for initiation of Pharmacotherapy in children with ADHD
12

A
  1. Diagnostic assessment complete and confirms diagnosis of ADHD
  2. Child is 6 years old or more
  3. Parents approval for medication therapy
  4. School will cooperate
  5. No previous sensitivity to the chosen medication
  6. Normal heart rate and blood pressure
  7. Child is seizure free
  8. Child does not have Tourette syndrome
  9. Child does not have Pervasive 10. Developmental Delay
  10. Child does not have significant anxiety
  11. Substance abuse among household members is not a concern
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31
Q

Medical therapy

two categories?

A

Stimlants and Nonstimulant medications

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32
Q

Medical therapy:
Stimulants? 2
Nonstimulant medications? 6

A
  1. Stimulants
    - Amphetamines
    - Methylphenidate
  2. Nonstimulant medications
    - Atomoxetine (Strattera)
    - Buproprion (Wellbutrin)
    - Tricyclic antidepressants
    - Selective Serotonin reuptake inhibitors
    - Monoamine oxidase inhibitors
    - Alpha adrenergic agonists
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33
Q

Pretreatment work-up

4

A
  1. A comprehensive, cardiovascular-focused patient history, family history, and physical examination should be completed.
  2. Measure vital signs and assess growth.
  3. A pretreatment baseline should be established for common side effects associated with pharmacotherapy for ADHD (eg, appetite, sleep pattern, headaches, abdominal pain).
  4. Adolescent patients should be assessed for substance use or abuse. Those with signs and symptoms of substance abuse should undergo evaluation and treatment for addiction before treatment for ADHD (if possible).
34
Q

Pretreatment visit
should include what?
6

A
  1. An explanation (to the patient) that the medication is being prescribed to help with self-control and ability to focus
  2. Review of risks and benefits of medical treatment
  3. An explanation of the process and expected length of time (ie, one to three months) for dose titration
  4. The frequency of follow-up
  5. The information that will be needed at follow-up visits or phone calls
  6. Behaviors/side effects that the family should monitor and report
35
Q 
What are the drugs that belong to each of these categories:
Methylphenidate
1. Immediate release? 2
2. Extended release? 3
3. Long acting? 3
A
    • Ritalin,
    • Methylin
  2. -Ritalin SR
    -Metadate ER
    -Methylin ER
  3. -Ritalin LA,
    -Metadate CD
    -Concerta
    Daytrana (patch)
36
Q 
What are the drugs that belong to each of these categories:
Dextroamphetamine
1. Immediate release? 1
2. Extended release? 2
3. Long acting? 1
4. Dexmethylphenidate? 1
A
  1. Formerly Dextrostat
    • Dexedrine Spansule,
    • Adderall
  3. Adderall XR
  4. Focalin
37
Q

Second line agent:

Atomoxetine: Brand name?

A

Strattera

38
Q

Third line agents

5

A
  1. Bupropion (SR and XR)
  2. Imipramine
  3. Desipramine
  4. Clonidine
  5. Guanfacine
39
Q

What are the Brand names of the following:

  1. Bupropion (SR and XR)
  2. Imipramine
  3. Desipramine
  4. Clonidine
  5. Guanfacine
A
  1. Wellbutrin
  2. Tofranil
  3. Norpramin
  4. Catapres
  5. Tenex
40
Q
  1. Medication for preschool children (4-5 year olds)
  2. As a PA I would avoid prescribing these medications to children under the age of
  3. Indicated if failure of what?
A
  1. methylphenidate rather than amphetamines or nonstimulant medications
  2. 6.
  3. behavioral therapy
41
Q

Autism spectrum disorders

3

A

Pervasive developmental disorders

  1. Autistic disorder
  2. Asperger syndrome
  3. Pervasive developmental disorder not otherwise specified
42
Q

Autism spectrum disorders affect 3 main areas of functioning

A
  1. Social interaction
  2. Communication
  3. Behaviors and interests
43
Q

Autistic behavior
1. Sometimes, a child’s development is delayed from birth. Some children seem to develop normally before they suddenly lose what? 2

  1. Others show normal development until they have enough language to demonstrate what? 2
  2. In some children, a loss of _________ is the major impairment.
  3. In others, what seems to be the dominant factors?
A
  1. social or language skills.
  2. unusual thoughts and preoccupations.
  3. language
  4. unusual behaviors (like spending hours lining up toys)
44
Q
  1. What is the mildest form of autism?
  2. Describe their behavior?
    4
A
  1. Asperger’s syndrome (AS)
    • Children with AS become obsessively interested in a single object or topic. They often learn all about their preferred subject and discuss it nonstop.
    • Impaired social interaction
    • Frequently have normal to above average intelligence
    • Adults with AS are at high risk for anxiety and depression
45
Q

Pervasive developmental disorder not otherwise specified (PDD-NOS)?

A
  1. Between Autism and Asperger’s in terms of severity of symptoms
  2. Symptoms vary widely
  3. Impaired social interaction (like all children with autistic spectrum disorder)
46
Q

PDD-NOS

  1. Describe language compared to asperbers and autism?
  2. Repetitive disorders?
  3. Age of onset comparitively?
A
  1. Better language skills than kids with autistic disorder but not as good as those with Asperger’s syndrome
  2. Fewer repetitive behaviors than children with Asperger’s syndrome or autistic disorder
  3. A later age of onset
47
Q

Autism
More severe impairments in what?
4

A
  1. social functioning
  2. language
  3. repetitive behaviors
  4. May also have mental retardation and seizures
48
Q

ASD AAP Policy Statement 2007

3 policies?

A
  1. Surveillance at every visit
  2. Four risk factors for surveillance
  3. Routine ASD screen at 18 months and 24 months
49
Q

According to AAP policy, risk factors for surveillance for ASD include:
4

If two or more, how should we act on this?

If 1 and child at least 18 mos old how should we act on this?

When screen is positive, refer for what?

A
  1. Sibling with ASD
  2. Parent concern, inconsistent hearing, unusual responsiveness
  3. Other caregiver concern
  4. Pediatrician concern

If 2 or more, refer for Early intervention (EI), ASD Evaluation, and Audiology simultaneously.

If 1 and child at least 18 mos old, use screening tool.

When screen is positive, refer for EI, ASD Evaluation, and Audiology

50
Q

ASD MCHAT
1. For what age groups?
2. WHo fills out the questionnaire?
3.

A

For 16-48 months

Questionnaire completed by parent

51
Q

ASD MCHAT sample items: Parent report

4

A
  1. Does your child take an interest in other children?
  2. Does your child ever use his/her index finger to point, to indicate interest in something?
  3. Does your child ever seem oversensitive to noise?
  4. Does your child imitate you?
52
Q

Red flags for ASD in the 2nd year*****

9

A
  1. Regression
  2. “In his own world”
  3. Lack of showing, sharing interest or enjoyment
  4. Using the caregivers hands to obtain needs
  5. Repetitive movements with objects
  6. Lack of appropriate gaze
  7. Lack of response to name
  8. Unusual prosody/pitch of vocalizations
  9. Repetitive movements or posturing of body
53
Q

ASD Goals of Treatment

4

A
  1. Minimize core features
  2. Maximize functional independence
  3. Maximize quality of life
  4. Maximize family function
54
Q

ASD Treatment is comprehensive
1. When should intervention start?

  1. 25 hours per week, 12 months per year in what kind of system?
  2. Social interaction?
A
  1. Intervention as soon as diagnosis suspected
  2. 25 hours per week, 12 months per year in “systematically planned, developmentally appropriate educational activities.”
    - -Low student:teacher ratio.
  3. Inclusive experience with typically developing peers
55
Q

ASD Educational interventions are the foundation of treatment
8

A
  1. Applied Behavioral Analysis
  2. Structured teaching – TEACCH
  3. Developmental
  4. Relationship focused
  5. Speech and Language Therapy, including use of augmentative and alternative communication
  6. Social Skills Instruction – joint attention
  7. OT (Sensory Integration)
  8. Therapy – evidence base not yet established
56
Q

ASD Common behavioral issues

5

A
  1. Disruption/aggression15-64%
  2. Self-injurious 8-38%
  3. Eating 25-52%
  4. Sleeping 36%
  5. Toileting 40%

Problems correlate with rigidity/restricted interests/need for sameness

57
Q

ASD Medical Management
Challenges in routine health care due to what? 4

Average visit requires ______ as much time as for a child without an ASD.

A
  1. difficulties with social interaction,
  2. communication, and
  3. negotiating a new and
  4. unfamiliar environment.
  5. twice
    - –Strategies in the office to promote familiarity
58
Q

ASD Associated medical conditions

3

A
  1. Gastrointestinal:
  2. Seizures
  3. Sleep problems
59
Q

Describe the associated problems with the following:

  1. Gastrointestinal:
  2. Seizures
A

Gastrointestinal:

  1. chronic constipation/diarrhea,
  2. recurrent abdominal pain.
    - Studies inconsistent, with rates of 9% to 70%

Seizures: 11 – 39%.
1. More likely with co-morbid severe global delays and motor deficits.

60
Q

Oppositional defiant disorder

ODD is a psychiatric disorder that is characterized by two different sets of problems?

A
  1. Aggressiveness

2. Tendency to purposefully bother and irritate others

61
Q

Definition of the behavior in ODD?

4

A
  1. Negative,
  2. manipulative,
  3. hostile
  4. defiant behavior
62
Q

Etiology of ODD

A

Family history
—If a parent is alcoholic and has been in trouble with the law, their children are almost three times as likely to have ODD.
18% of children in this situation will have ODD

63
Q

DSM-5 criteria for diagnosis of ODD

Need _____ signs and symptoms listed below

A

4 of 8

64
Q

DSM-5 criteria for diagnosis of ODD

  • Angry/Irritable Mood 3
  • Argumentative/Defiant Behavior 4
  • Vindictiveness 1
A

Angry/Irritable Mood

  1. Often loses temper
  2. Is often touchy or easily annoyed
  3. Is often angry and resentful

Argumentative/Defiant Behavior

  1. Often argues with authority figures
  2. Often actively defies or refuses to comply with requests from authority figures
  3. Often deliberately annoys others
  4. Often blames others for mistakes or misbehavior

Vindictiveness
1. Has been spiteful or vindictive at least twice within the past 6 months

65
Q

Prognosis for ODD?

4

A
  1. There will be some lucky children who outgrow this. About half of children who have ODD as preschoolers will have no psychiatric problems at all by age 8.
  2. ODD may turn into something else. About 5-10 % of preschoolers with ODD will eventually end up with ADHD and no signs of ODD at all. Other times ODD turns into conduct disorder (CD).
  3. The child may continue to have ODD without any thing else. only 5%
  4. They continue to have ODD but add on comorbid anxiety disorders, comorbid ADHD, or comorbid Depressive Disorders. By the time these children are in the end of elementary school, about 25% will have mood or anxiety problems which are disabling.
66
Q

Treatment
of ODD?
4

A
  1. Referral to Pediatric Psychiatrist
  2. Meds for co-morbid disorders
  3. Behavioral therapy
  4. Parental therapy for setting clear boundaries
67
Q

Describe conduct disorder?

A
  • Group of behavioral and emotional problems in children
  • Significant difficulty following rules and behaving in a socially acceptable way
  • Often viewed as “bad” kids or delinquents
68
Q

Conduct disorder:
Factors that may contribute to this mental illness include?
6

A
  1. Brain damage
  2. Child abuse
  3. Neglect
  4. Genetic vulnerability
  5. School failure
  6. Traumatic life experiences
69
Q

Conduct disorder vs. Oppositional defiant disorder.
Conduct disorder is just a worse version of ODD

However recent research suggests that there are some differences? 3

A
  1. Children with ODD seem to have worse social skills than those with CD.
  2. Children with ODD seem to do better in school.
  3. Conduct disorder is the most serious childhood psychiatric disorder.
70
Q

Co-morbid conditions that may be associated with conduct disorder
7

A
  1. Depression or anxiety disorder (25-50%)
  2. Post traumatic stress disorder
  3. Substance abuse
  4. ADHD (30-50%)
  5. Learning problems
  6. Bipolar disorder
  7. Tourette’s syndrome
71
Q

Conduct disorder is characterized by

4

A
  1. Aggression to people and animals
  2. Destruction of property (arson)
  3. Deceitfulness, lying or stealing
  4. Serious violations of the rules
72
Q

Aggression to people and animals in conduct disorder could include what?
6

A
  1. Bullies, threatens or intimidates
  2. Physical fights
  3. Use of weapons to harm others (bat, brick, firearm, etc.)
  4. Physically cruel to people or animals
  5. Steals
  6. Forces others into sexual acts
73
Q
  1. Treatment for conduct disorder: Referral to Psychiatrist for ? 4
  2. Without treatment become adults with what?
A
  1. Behavioral therapy +
  2. Psychotherapy +
  3. Parental support and training +
  4. Medications for comorbid conditions such as ADHD, depression or anxiety if present

antisocial behavior and ongoing problems with relationships and employment

74
Q

Depression definition?

Criteria?

A

Relatively common psychiatric condition that generally continues episodically into adulthood

Criteria for diagnosis is identical to that in adults

75
Q

A major depressive episode in children and adolescents typically includes at least 5 of the following symptoms (including at least 1 of the first 2) during the same 2-week period:
9

A
  1. Depressed (or irritable) mood
  2. Diminished interest or loss of pleasure in almost all activities
  3. Sleep disturbance
  4. Weight change, appetite disturbance, or failure to achieve expected weight gain
  5. Decreased concentration or indecisiveness
  6. Suicidal ideation or thoughts of death
  7. Psychomotor agitation or retardation
  8. Fatigue or loss of energy
  9. Feelings of worthlessness or inappropriate guilt
76
Q

Medical evaluation to rule out other etiologies

6

A
  1. Infection
  2. Medication
  3. Endocrine disorder
  4. Tumor
  5. Neurologic disorder
  6. Miscellaneous disorders
77
Q

Signs and symptoms of major depression

SIGECAPS

A 
S	Sleep disturbance
I	Interests (decreased for usual activities)
G	Guilt (excessive or inappropriate)
E	Energy (decreased)
C	Concentration problems
A	Appetite change
P	Pleasure (decreased)
S	Suicidal thoughts or actions
78
Q

Types of Treatment for depression?

3

A
  1. Psychotherapy
  2. Medical therapy
  3. Combination of both
79
Q

Medical treatment with SSRIs (selective serotonin reuptake inhibitors)
2

A

Fluoxetine (Prozac)
(FDA approved ages 8-17)

Escitalopram (Lexapro)
(FDA approved ages 12-17)

80
Q

SSRI black box warning

A

Increased suicidality risk in children, adolescents, and young adults w/ major depressive or other psychiatric disorders; weigh risk vs. benefit; in short-term studies of antidepressants vs. placebo, suicidality risk not increased in patients >24 years old, and risk decreased in patients >65 years old.

81
Q

What you should know about treating pediatric depression:

  1. It is NOT a ____________ in children and teens
  2. Often occurs with other ___________?
  3. Rule out medical causes of symptoms including? 2

Ok to do initial work up and assessment but ALWAYS involve your supervising physician

A
  1. benign condition
  2. psychiatric conditions

3, (anemia, hypothyroidism)

Pediatrics (18 decks)

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