Psychiatry/Learning Issues

Question 1

First line treatment of depression in adolescents

Answer 1

• Fluoxetine (SSRI) - contraindicated in patients taking MAO inhibtors, caution in kids on diuretics and with liver/kidney disease
• Side effects: Headache, insomnia, GI upset, weight loss
• Inhibits CYP450 so concomitant drug levels can increase

Question 2

Number 1 cause of preventable intellectual disability

Answer 2

Congenital hypothyroidism

Question 3

Most common inherited cause of intellectual disability

Answer 3

Fragile X (uncles with learning problems)

Question 4

Most common teratogen causing intellectual disability

Answer 4

Alcohol –> also at risk for neurobehavioral deficits even with a normal IQ

Question 5

Best indicator of cognitive function in young children

Answer 5

Language development is better than motor development

Question 6

Autism spectrum diagnosis

Answer 6

• Persistent deficits in social communication and social interaction across contexts (not accounted for by general developmental delays)
• Presence of restricted, repetitive, stereotyped behavior, interests, activities
• Lack of eye contact and lack of social engagement is key*

Question 7

Learning disability red flags

Answer 7

• Inability to recognize letters and numbers by the end of kindergarten
• Speech delay in preschool
• Inability to read simple words by the end of first grade

Question 8

Dyslexia can be normal until when

Answer 8

Age 7

Question 9

Medications that can alter school performance

Answer 9

Anticonvulsants and antihistamines

Question 10

Specific learning disability testing

Answer 10

Below normal scores on an achievement test but a normal IQ

Question 11

Colic definition

Answer 11

• Between 3 weeks and 3 months
• Crying for more than 3 hours per day, more than 3 days per week, for more than 3 weeks
• Tend to draw up thier legs, tense their abdomens, and arch their backs
• Tx: use another caregiver to take over (no gas drops or meds)
• 5 S’s: swaddling, shushing, swinging, sucking, strolling

Question 12

Normal baby crying amounts

Answer 12

Birth to 6 weeks: up to 2 hours a day

6 weeks and beyond: up to 3 hours a day

Question 13

Breath holding spells

Answer 13

• Most common in ages 6-18 months
• Can be associated with iron deficiency anemia (not a cause but treating the anemia can improve them)
• Most severe form is hypoxic seizure with a postictal period
• Tx: behavioral modification

Question 14

Head banging behaviors

Answer 14

• Neurologically intact and between 8 months to 4 years –> normal and no intervention is necessary
• If older than 4 and/or signs of developmental delay, then needs a workup
• If head banging plus other symptoms should consider neglect as well

Question 15

Thumb sucking treatment

Answer 15

• Initial intervention: redirection, positive reinforcement when not sucking thumb
• No active measures until after age 4
• Prolonged thumb sucking can lead to dental problems (malocclusion)

Question 16

Phobia definition

Answer 16

• Anxiety based on potential danger posed, must interfere with daily function for at least 6 months
• Tx: desensitization, cognitive behavioral techniques

Question 17

ADHD symptoms

Answer 17

• Inattentiveness, impulsivity, hyperactivity
• Must be present before age 12 and in 2 or more settings
• Must impair functioning and be present for at least 6 months, not explained by another condition

Question 18

ADHD hyperactivity vs inattentive types

Answer 18

Hyperactive more common in males, inattentive more common in girls

Question 19

Risk factors for ADHD

Answer 19

• Maternal tobacco and/or alcohol use, lead exposure, low birthweight, prematurity, IUGR

Question 20

ADHD neurochemical findings

Answer 20

• Areas of the brain rich in dopaminergic and noradrenergic pathways are less activated in kids with ADHD

Question 21

Things to rule out instead of ADHD

Answer 21

• Absence seizures
• Depression, anxiety
• Substance abuse
• Visual/hearing deficits
• Lead toxicity
• Hyper/hypothyroidism
• Previous neuro damage (infection, trauma)
• Phenobarbital, antihistamines

Question 22

ADHD Comorbidities

Answer 22

65% of kids with ADHD have a coexisting condition

- Oppositional defiant disorder, conduct disorder, mood disorder, anxiety disorder, learning disorder

Question 23

Stimulants

Answer 23

• First line for ADHD
• Methylphenidate, amphetamine
• Caution in kids with heart conditions, psychiatric conditions, and seizures
• Can increase serum concentations of TCAs and seizure meds

Question 24

Stimulant plus MAO inhibitor side effect

Answer 24

Hypertensive crisis

Question 25

Stimulant side effects

Answer 25

• Insomnia, weight loss, anorexia, rash, tachycardia, GI issues, hypertension, palpitations, headaches, visual disturbances
• Less common: abnormal liver enzymes, hair loss
• Can unmask tics in kids with Tourettes but does not cause Tourette syndrome
• Isolated motor tics on stimulants is usually transient, not a contraindication

Question 26

Nonstimulants for ADHD

Answer 26

• Atomoxetine (norepinephrine reuptake inhibitor) - use caution in patients with cardiac conditions or concurrent albuterol therapy, increased SI in teenage boys
• Clonidine, guanfacine (alpha adrenergic agonists)

Question 27

Depression signs/symptoms

Answer 27

• Acting out can be a symptom
• Normal things - keep in mind if interfering with daily functioning and beyond the limits of normal, it’s often depression
• Increased risk: parental depression, chronic illness

Question 28

Mania after starting antidepressant

Answer 28

Stop med right away and consider bipolar

Question 29

Amitriptyline

Answer 29

• TCA
• Can’t be used in kids with seizures and severe cardiac disorders
• Metabolized in CYP450
• Can’t stop it abruptly
• Side effects: sedation, urinary retention, constipation, dry mouth, dizziness, drowsiness, arrhythmias
• Monitoring: EKG, BP, CBC at start of therapy and with dose changes

Question 30

Escitalopram

Answer 30

• Can be used for depression in adolescents but requires QT monitoring

Question 31

Oppositional defiant disorder

Answer 31

• Defiant, disobedient, hostile behaviors

- Little respect for authority

Question 32

Conduct disorder

Answer 32

• Severe behavioral concerns (lying, stealing, cruelty to animals) that impinge on the basic rights of others or violate major age appropriate social rules
• For at least 6 months

Question 33

Obsessive compulsive disorder

Answer 33

• Repetitive behaviors (compulsions) with recurrent thoughts and worries (obsessions)
• Can be a symptom of PANDAS (Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal infection)

Question 34

Bipolar disorder

Answer 34

• Major depressive episode can be presentation –> start med –> manic
• High rate of coexisting ADHD and psychiatric disorders
• Family history is biggest predictor

Question 35

Conversion disorder

Answer 35

Symptoms incompatible with anatomical and medical logic

Question 36

Hypochondriasis

Answer 36

Preoccupation with illness, frequently in the context of previous illness

Question 37

Malingering

Answer 37

Presenting with false or exaggerated symptoms, often with a motive

Question 38

Dysmorphic disorder

Answer 38

Patient perceives themselves as being ugly or undesirable

Question 39

Somatic delusions

Answer 39

Belief that something is medically wrong and may take on psychotic dimensions

Question 40

Factitious disorder/Munchausen by Proxy

Answer 40

• Usually the mom
• Consider if: unexplained persistance/recurrence of symptoms, child looks healthier than history/labs indicate, symptoms are unusual, symptoms don’t occur if they’re with someone else, mom refuses to leave kids side, negative work ups don’t reassure the mom, reported history is confusing, has seen multiple specialists
• Tx: CPS report, remove child from parent and see if symptoms occur