Psych Flashcards
1
Q
Sxs of ADHD?
A
- manifests in children with sxs of hyperactivity, impulsivity and/or inattention
- sxs affect cognitive, academic, behavioral, emotional and social fxning
2
Q
Prevalence of ADHD?
A
- in school age kids: 8-10% - one of the most common disorders of childhood - male to female ratio: 4:1 for predom hyperactive type 2:1 for predom inattentive type
3
Q
What other comorbid psych disorders do children with ADHD have?
A
- oppositional defiant disorder
- conduct disorder
- depression
- anxiety disorder
- learning disabilities
4
Q
Pathogenesis of ADHD?
A
- a genetic imbalance of catecholamine metabolism in cerebral cortex appears to play a primary role
- various eviro factors may play a secondary role: controversial
5
Q
Cerebral structural and fxnl abnormalities in prefrontal structures and basal ganglia regions result in?
A
- impaired executive fxns (processes involved in forward planning, including abstract reasoning, mental flexibility, working memory)
- impulsivity
6
Q
What are some dietary influences on ADHD?
A
areas of investigation:
- food additives (artificial colors, artificial flavors, preservatives)
- refined sugar intake
- food sensitivity (allergy or intolerance)
- essential fatty acid deficiency
- iron and zinc deficiency
7
Q
What are some possible associations with ADHD?
A
- prenatal exposure to tobacco
- prematurity and low birth wt
- prenatal exposure to alcohol
- head trauma in young children
- maternal acetaminophen use??
- High correlation b/t FAS and ADHD
8
Q
What ADHD sxs do most kids display from time to time?
A
- inattentiveness, impulsivity, and hyperactivity occur to some extent in all kids
- it is the persistence, pervasiveness, and fxnl complications of the behavioral sxs that lead to dx of ADHD
9
Q
Criteria for ADHD?
A
- be present in more than one setting (school and home)
- persist for at least 6 months
- be present b/f age of 12
- impair fxn in academic, social or occupational activities
- be excessive for developmental level of the child
- not be caused by other mental disorders
10
Q
2 categories of core sxs?
A
- hyperactivity/impulsivity
- inattention
- each of the core sxs of ADHD has its own pattern and course of development
11
Q
Sxs of hyperactivity may include?
A
- excessive fidgetiness (tapping hands or feet, squirming in seat)
- difficulty remaining seated when sitting is reqd (school, work)
- feelings of restlessness (adolescents) or inappropriate running around or climbing in younger children
- difficulty playing quietly
- difficult to keep up with, seeming to always be “on the go”
12
Q
Sxs of impulsivity?
A
- excessive talking
- difficulty waiting turns
- blurting out answers too quickly
- interruption or intrusion of others
13
Q
When are hyperactive sxs usually observed?
A
- by the time the child reaches 4 yo
- increase during the next 3-4 years, peaking in severity when the child is 7-8 years old
- older than 8:
hyperactive sxs begin to decline, by adolescent years sxs may not be noticeable to others although may feel restless or unable to settle down - impulsive sxs: usually persist throughout life
14
Q
Sxs of inattention?
A
- failure to provide close attention to detail, careless mistakes
- difficulty maintaining attention in play, school or home activities
- seems not to listen, even when directly addressed
- fails to follow through (homework, chores)
- difficulty organizing tasks, activities, and belongings
- avoid tasks that reqr consistent mental effort
- loses objects reqd for tasks or activities (school books, sports equipment)
- easily distracted by irrelevant stimuli
- forgetfulness in routine activities (homework, chores)
15
Q
Inattentive subtype of ADHD?
A
- children with inattentive subtype often are described as having a sluggish cognitive tempo and frequently appear to be daydreaming or “off task”
- typical presenting complaints center on cognitive and/or academic problems
- sxs of inattention typically aren’t apparent until the child is 8-9 yo and usually are lifelong problem
16
Q
Sxs of ADHD may impair fxns in which 3 areas?
A
- academic
- social: social skills in kids with ADHD often are significantly impaired
- occupational
17
Q
Eval of child with suspected ADHD?
A
- medical
- developmental
- educational
- psychosocial eval
18
Q
What ?s should you ask the parents of child during your eval?
A
- how is child doing in school?
- have you or the teacher noticed any problems with learning?
- is your child happy in school?
- does your child have any behavioral problems at school or at home, or when playing with friends?
- does your child have problems completing school assignments at school or home?
19
Q
Medical eval: Hx?
A
- prenatal exposures (tobacco, drugs, alcohol)
- perinatal complications or infections
- CNS infection
- head trauma
- recurrent otitis media
- meds
- family Hx of similar behaviors is impt b/c ADHD has a strong genetic component
20
Q
Medical eval: PE?
A
- measurement of ht, wt, head circumference, and vital signs
- assessment of dysmorphic features and neurocutaneous abnormalities
- a complete neuro exam, including assessment of vision and hearing
- observation of child’s behavior in office setting
21
Q
Developmental and behavioral assessment?
A
- specific info about onset, course and fxnl impact of ADHD sxs
- emotional, medical and developmental events that may provide an alternative explanation for the sxs
- developmental milestones, particularly language milestones
- school absences
- psychosocial stressors
- observation of parent-child interactions
22
Q
Behavior rating scales?
A
- various scales have been developed to colelct structured observations of behavior
- completion of these scales by parents and teachers during dx eval helps to establish the presence of core sxs of ADHD in more than one setting
23
Q
ADHD specific scales (narrow band scales) usuefulness?
A
- can be used to est. presence of core sxs of ADHD
- the validity of ADHD rating scales in distinguishing children with ADHD from age matched control children varies depending upon the age of the child, the scale that is used, and the informant (parent, teacher, adolescent)
24
Q
Usefulness of broadband scales?
A
assess a variety of sxs:
- internalizing behaviors (feeling depressed, anxious, withdrawn)
- externalizing behaviors other than ADHD (aggression)
- broadband scales are not recommended to establish the presence of core sxs of AHD: they are less sensitive and specific (less than 86%) than ADHD specific scales
- help to ID coexisting conditions and narrow the differential dx
25
Educational eval?
- child's teacher to complete ADHD specific rating scale
- a narrative summary of classroom behavior and interventions, learning patterns, and fxnl impairment
- copies of report cards and samples of schoolwork
- review of school based multidisciplinary evals
26
What does the DSM-5 (diagnostic and statistical manual of mental disorders 5th edition) require for the dx of ADHD?
- 6 or more sxs of hyperactivity and impulsivity
- or 6 or more sxs of inattention
- for adolescents 17 and older - 5 or more sxs of hyperactivity and impulsivity or 5 or more sxs of inattention are reqd
sxs of hyperactivity/impulsivity or inattention must:
- occur often
- be present in more than 1 setting (school, home)
- persist for at least 6 months
- be present before the age of 12
- impair fxn in academic, social, or occupational activities
- be excessive for developmental level of child
27
3 ADHD subtypes dx criteria?
- predominantly inattentive: 6 or more sxs of inattention for children less than 17, and 5 or more sxs for adolescents 17 and older
- predominantly hyperactive-impulsive: 6 or more sxs of hyperactivity impulsivity for children younger than 17, and 5 or more sxs for adolescents 17 and older
- combined: 6 or more sxs of inattention and 6 or more sxs of hyperactivity- impulsivity for children younger than 17
- 5 or more sxs in each category for adolescents 17 and older
28
Tx options for ADHD?
- behavioral interventions
- meds
- school based interventions
- psych interventions alone or in combo
29
Tx goals?
target outcomes include improved:
- relationships with parents, teachers, siblings, or peers
- academic performances (complete assignments)
- rule following (doesn't talk back to teacher)
30
Indications for referral for pt with ADHD?
- coexisting psych conditions (oppositional defiant disorder, conduct disorder, substance abuse, emotional problems)
- coexisting neuro, or medical conditions (seizures, tics, autism spectrum disorder, sleep disorder)
- lack of response to a controlled trial of stimulant therapy or atomoxetine
31
Who would you refer to?
- developmental behaviroal pediatrician
- child neurologist (if comorbid neuro condition)
- psychopharmacologist
- child psychiatrist
- clinical child psychologist
32
Criteria for initiation of pharmacotherapy in kids with ADHD?
- dx assessment complete and confirms dx of ADHD
- child is 6 or older
- parents approval of med
- school will cooperate
- no previous sensitivity to chosen med
- normal HR and BP
- child is seizure free
- child doesn't have Tourette syndrome
- child doesn't have pervasive developmental delay
- child doesn't have sig anxiety
- substance abuse among household members isn't a concern
33
Categories of medical therapy?
```
- first line -stimulants:
amphetamines, and methylphenidate
- nonstimulant meds:
atomoxetine (strattera)
buproprion (wellbutrin)
TCAs
SSRIs
MAOIs
alpha adrenergic agonists (lower efficacy)
```
34
Pretx work up of ADHD?
- comprehensive, cardiovascular focused pt hx, family hx, and physical exam should be done
- vital signs and growth
- pretx baseline should be established for common SEs assoc with pharmacotherapy for ADHD (appetite, sleep pattern, HAs, and abdominal pain)
35
Pretx visit should include?
- explanation to the pt that the med is being prescribed to help with self control and ability to focus
- review of risks and benefits of medical tx
- an explanation of process and expected length of time (1-3 months) for dose titration
- frequency of f/u
- information that will be needed at follow up visits or phone calls
- behaviors/side effects that family should monitor and report
36
First line agents - stimulants?
methylphenidate:
- immediate release - ritalin, methylin
- extended release: ritalin SR, metadate ER, Methylin ER
- long acting: ritalin LA, metadate CD, concerta, daytrana (patch)
dextroamphetamine:
- short acting: dextrostat
- intermediate acting: dexedrine, spansule, adderall
- long acting: adderall XR
- Dexmethylphenidate - focalin
37
2nd line agent?
- atomoxetine: strattera
38
3rd line agents?
- Buproprion: wellbutrin
- imipramine: tofranil
- desipramine: norpramin
- clonidine: catapres
- guanfacine: tenex
39
Meds for preschool kids (4-5 yo)
- methylphenidate rather than amphetamines or non stimulant meds
- avoid rx these meds to kids under age of 6
- indicated if failure of behavioral therapy
40
3 Pervasive developmental disorders (autism spectrum disorders)?
- autistic disorder
- asperger syndrome
- pervasive developmental disorder not otherwise specified
41
Prevalence of autism spectrum disorders?
- affects 1/88 US children
| - more common in boys than girls
42
Etiology of autism spectrum disorders?
- thought to be secondary to enviro, biologic and genetic factors
- genetic: sibling or parent with an autism spectrum disorder increases the risk
- prenatal exposure to valproic acid or thalidomide
- prematurity and or low birth wt
- vaccines are not assoc with autism
- children born to older parents at higher risk
- co-occurs with other developmental, psych, neuro, xsomal (down syndrome, fragile x, tuberous sclerosis), and genetic dxs
43
Autism spectrum disorders affect what 3 main areas of fxning?
- social interaction
- communication
- behaviors and interests
44
Manifestation of autistic behavior?
- sometimes, child's development delayed from birth. Some children seem to develop normally before they suddenly lose social or language skills. Others show normal development until they have enough language to demonstrate unusal thoughts and preoccupations
- in some kids, loss of language is major impairment. In others, unual behaviors (like spending hours lining up toys) seem to be dominant factors
45
What is Aspergers syndrome?
- mildest form of autism, affects boys 3x more than girls. Kids with AS become obsessively interested in single object or topic, they often learn all about their preferred subject and discuss it nonstop
- impaired social interaction
- frequently have normal to above avg intelligence
- adults with AS are high risk for anxiety and depression
46
What is PDD-NOS?
- pervavsive developmental disorder not otherwise specified
- b/t autism and aspergers in terms of severity of sxs
- sxs vary widely
- impaired social interaction (like all kids with autistic spectrum disorder)
- better language skills than kids with autism but not as good as those with aspergers
- fewer repetitive behaviors than kids with AS or autism
- a later age of onset
47
Autism's main features?
- more severe impairments in:
social fxning
language
repetitive behavior: wringing hands, lip smacking, oral fixation
- may also have mental retardation and seizures
48
AAP policy statement 2007 criteria?
- surveillance at q visit
- 4 risk factors for surveillance
- routine ASD screen at 18 months and 24 months
49
RFs for ASD according to AAP policy?
- sibling with ASD
- parent concern, inconsistent hearing, unusual responsiveness
- other caregiver concern
- pediatrician concern
- if 2 or more refer for EI, ASD eval, and audiology simultaneously
50
Routine screening tools for ASD?
- screen specifically for ASD at 18 and 24 months
- parent fills out form
- MCHAT: modified checklist for autism in toddlers
- STAT: screening tool for autism in toddlers and young children
51
MCHAT specifics?
- for 16-48 months
- sensitivity: 85%, and specificity of 93%
- questionnaire completed by parent
- 5-10 minutes to complete (parent)
- simple scoring
parent report:
does your child take an interest in other kids?
does your child ever use his/her index finger to pt to indicate interest in something?
does your child ever seem oversensitive to noise?
Does your child imitate you?
52
Red flags for ASD in 2nd year?
- regression
- "in his own world"
- lack of showing, sharing interest or enjoyment
- using caregivers hands to obtain needs
- repetitive movements with objects
- lack of appropriate gaze
- lack of response to name
- unusual prosody/pitch of vocalizations (sing song and rhymes)
- repetitive movements or posturing body - toe walking
53
Goals of tx of ASD?
- minimize core features
- maximize fxnl independence
- max. quality of life
- max. family fxn
54
Tx of ASD?
- - intervention as soon as dx suspected
- 25 hrs/week, 12 months/year in systematically planned, developmentally appropriate educational activities
- low student:teacher ratio
- inclusive experience with typically developing peers
55
What is the foundation of tx ASD?
educational interventions:
- applied behavioral analysis
- structured teaching
- developmental
- relationship focused
- speech and language therapy, including use of augmentative and alternative communication
- social skills instruction - jt attention
- OT (sensory integration) therapy: evidence base, not yet established
56
Common behavioral issues of ASD?
- disruption/aggression: 15-64%
- self-injurious: 8-38%
- eating: 25-52%
- sleeping: 36%
- toileting: 40%
- problems correlate with rigidity/restricted interests/ need for sameness
57
Medical management for ASD?
- challenges in routine health care due to difficulties with social interaction, communication, and negotiating a new and unfamiliar enviro
- avg visit reuqires 2x as much time as child without ASD
- strategies in office to promote familiarity
58
Assoc medical conditions with ASD?
- GI: chronic constipation/diarrhea, recurrent abdominal pain. Studies inconsistent, with rates of 9-70%
- seizures: 11-39%, more likely with co-morbid severe global delays and motor deficits
- sleep problems
59
What is ODD?
- psych disorder that is characterized by 2 diff sets of problems:
- aggressiveness
- tendency to purposefully bother and irritate others
- defined as: negative, manipulative, hostile, and defiant behavior
60
Etiology of ODD?
- family hx
- if parent alcoholic and has been in trouble with the law, their children are 3x as likely to have ODD: 18% of children in this situation will have ODD
61
DSM-5 criteria for dx of ODD?
need 4 of 8 signs and sxs listed below:
- angry/irritable mood: often loses temper, is often touchy or easily annoyed, is often angry and resentful
- argumentative/defiant behavior: often argues with authority figures, often actively defies or refuses to comply with requests from authority figures
- often deliberately annoys others
- often blames others for mistakes or misbehavior
- vindictiveness: has been spiteful or vindictive at least twice within past 6 months
62
Prognosis of ODD?
1. there will be some lucky children who outgrow this. About half of children who have ODD as preschoolers will have no psych probs at all by 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 w/o anything 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 end of elementary school, about 25% will have mood or anxiety problems which are disabling
63
Tx of ODD?
- referral to pediatric psychiatrist
- meds for co-morbid disorders
- behavioral therapy
- parental therapy for setting clear boundaries
64
What is conduct disorder?
- group of behavioral and emotional problems in kids
- significant difficulty following rules and behaving in socially acceptable way
- often viewed as bad kids or delinquents
- factors that may contribute to this mental illness:
brain damage
child abuse
neglect
genetic vulnerability
school failure
traumatic life experiences
65
Difference b/t ODD and CD?
- CD - just worse version of ODD
however recent research suggests that there are some differences:
- children with ODD seem to have worse social skills than those with CD (CD - manipulative)
- children with ODD seem to do better in school
- CD is most serious childhood psych disorder:
6-10% of boys and 2-9% of girls
These are future serial killers
66
Co-morbid conditions that may be assoc with conduct disorder?
- depresison or anxiety (25-50%)
- PTSD
- substance abuse
- ADHD (30-50%)
- learning probs
- bipolar
- tourettes
67
How is CD characterized?
aggression to people or animals:
- bullies, threatens or intimidates
- physical fights
- use of weapons to harm others (bat, brick, firearm)
- physically cruel to people or animals
- steals
- forces others into sexual acts
destruction of property (arson)
deceitfulness, lying or stealing
serious violations of the rules
68
Tx for CD?
referral to psych for:
- behavioral therapy +
- psychotherapy +
- parental support and training +
- meds for comorbid conditions such as ADHD, depression or anxiety if present
- w/o tx become adults with antisocial behavior and ongoing problems with relationships and employment
69
Prognosis of CD?
- 30% will continue to have similar problems in adulthood
- 4x more likely to have personality disorder when they grow up
- about 50-70% of 10 yr olds with CD will be abusing substances 4 years later
- cigarette smoking also very high
- girls with conduct disorder when compared to girls w/o CD:
6x more likely to abuse drugs or alcohol, 8x more likely to smoke cigs daily, 2x as likely to have STIs, 2x number of sexual partners, 3x as likely to become pregnant
70
Depression in peds?
- relatively common psych conditon that generally continues episodically into adulthood
- criterial for dx is identical to that of adults
- a major depressive episode in kids and adolescents typically includes at least 5 of the following sxs (including at least 1 of the first 2) during same 2 week period:
- depressed (or irritable) mood
- diminished interest or loss of pleasure in almost all activities
- sleep disturbance (insomnia or sleeping all the time)
- wt change, appetite disturbance, or failure to achieve expected wt gain
- decreased concentration or indecisiveness
- suicidal ideation or thoughts of death
- psychomotor agitation or retardation
- fatigue or loss of energy
- feelings of worthlessness or inappropriate guilt
71
Medical eval should be included to rule out what other possible etiologies that could appear as depression?
- infection
- meds
- endocrine disorder (thyroid - hypo or hyper)
- tumor
- neuor disorders
- miscellaneous disorders
72
Signs and sxs of major depression?
- S: sleep disturbances
- I: interests (decreased)
- G: guiilt (excessive or inappropriate)
- E: energy (decreased)
- C: concentration probs
- A: appetite change
- P: pleasure (decreased)
- S: suicidal thoughts or actions
73
How common is suicide in peds?
- 3rd leading cause of death in adolescents
| - risk of suicide may increase as pt recovers some from depression and has more energy and motivation
74
Tx of depression?
- psychotherapy
- medical therapy
- combo of both (most beneficial)
75
SSRIs?
- fluoxetine (prozac): FDA approved ages 8-17
| - escitalopram (lexapro): FDA approved ages 12-17
76
SSRI BBW?
- increased suicidality risk in kids, adolescents, and young adults with major depressive or other psych disorders, weigh risks vs benefit, in short term studies of antidepresants vs placebo, suicidality risk not increased in pts older than 24, and risk decreased in pts older than 65
77
Tips on tx pediatric depression?
- not a benign condition in children and teens
- often occurs with other psych conditions
- risk of suicide increases beyond that of placebo when using SSRIs (BBW)
- ok to do initial work up and assessment but always involve supervising physician
- rule out medical causes of sxs (anemia, hypothyroidism)
