Psychosocial Issues Flashcards
What % of kids have full bladder and bowel control by 36 months?
75%
What is the preferred way to toilet train?
Positive reinforcement- Praise/rewards (vs. punishment-based which rarely works)
What is primary nocturnal enuresis (PNE)?
Enuresis in a child who has never been dry on consecutive nights for 6 months
After what age can you diagnose primary nocturnal enuresis?
5
What is secondary nocturnal enuresis?
Kids who start bed wetting after being dry for 6 months
What is the initial workup for nocturnal enuresis?
- History
- Physical Exam
- UA
If there is history of primary nocturnal enuresis in one parents, what is the % chance the child will have it?
40%
If there is history of primary nocturnal enuresis in two parents, what is the % chance the child will have it?
70%
What are 4 organic causes of nocturnal enuresis to consider?
- Sickle cell trait
- Urinary tract infection or anomaly
- Diabetes
- Seizure or Sacral defect
What are 4 things to consider for a child with secondary nocturnal enuresis?
- Severe snoring/sleep disruption
- UTI or diabetes
- Constipation
- Stress: Moves, divorce, abuse, ect.
What is the most effective strategy for curing nocturnal enuresis?
Enuresis alarms
*Require intense effort, can take 3-4 months to work
What % of cases of enuresis per year will resolve with no intervention?
15%
Name 3 non-organic causes of enuresis
- Small bladder
- Excessive fluid intake before bed
- Deep sleeping
What are 3 behavioral modifications used to help with nocturnal enuresis?
- Limiting nighttime fluids 2 hours before bedtime
- Limiting dairy products 4 hours before bedtime
- Double voiding prior to going to bed
If you are considering using desmopressin as a treatment option for primary nocturnal enuresis, which form does the FDA advise not to use?
Intranasal form- Risk of severe hyponatremia and seizures
Which form of desmopressin is acceptable to use for primary nocturnal enuresis?
Tablet form
How long is desmopressin given for primary nocturnal enuresis?
6 months, then stop for 2 weeks to see if problem resolved
What is a common problem when using desmopressin for primary nocturnal enuresis?
Relapse after resolution
What is the likely problem for a child with diurnal enuresis after a period of daytime continence?
Behavioral (waiting too long to go to bathroom)
Diurnal enuresis cannot be diagnosed prior to what age?
3
What should you consider for diurnal enuresis besides behavioral?
- UTI
- DM
- DI
- Kidney disease
What lab should you get with diurnal enuresis?
UA
Why do children typically hold stool?
Because it either hurt in the past or they think it will hurt…causes bigger/more painful stools and vicious cycle
What can be used for older kids who withhold stool?
Laxatives
What happens if laxatives are discontinued too soon in kids who were started due to withholding stool?
Recurrence of stool withholding
When is a workup for Hirschsprung’s disease indicated in an older child who withholds stool?
Only if they have had constipation since infancy
Why is chronic constipation sometimes associated with UTIs?
Stasis and urinary retention
What is a child’s response to divorce dependent on?
Developmental stage
What is a child’s response to illness in the family dependent on?
Developmental stage
What are 2 typical responses to divorce and other stressors?
- Somatization
2. Regression of developmental milestones
What has been a result of the increase in joint custody arrangements?
Involvement of divorced fathers in their children’s lives
What is one negative impact of joint custody?
Increased conflict between parents- often has negative effect on children
What are two things which can happen to children of divorce?
- Difficulties with intimate relationships (like marriage) as adults
- Increased conflict in workplace
What is the typical response for a pre-school age child (2-5) to divorce?
Regression of most recently obtained developmental milestones
What is the typical response for an early school age child (6-8) to divorce?
Overt grieving, fear of rejection, guilt, fantasies that parents will get back together
What is the typical response for a late school age child (9-12) to divorce?
Anger at one or both parents, open mourning to the loss of the safety and structure of an intact family
What is the typical response for teenagers to divorce?
Depression and acting out, suicidal thoughts or ideation
*Teens can fake indifference, but true indifference is never correct
75% of kids recover within what timeframe after the immediate adjustment to a significant life stressor (death or divorce)?
2-3 years (unless new stresses keep appearing)
What does a child’s response to a death in the family depend on?
Age of child
Which 2 life stressors have similar impact on a child?
- Death in family
- Divorce
*Both involve loss
What is the typical response of a pre-schooler to death in the family?
- Confuse death with sleep or believe death is temporary
- Blame their thoughts/actions for death as a result of “magical thinking”
- Regression of developmental milestones
- Acting out/tantrums
What is the typical response of a school-age child to death in the family?
- Somatic complaints
- Sleep disturbance
- Decreased school performance
- Morbid fascination with death
- Figure out their own mortality
What is the typical response of a teenage to death in the family?
- Acting out
- “Why not me”
- Challenge mortality/take more risks
True or False: No additional intervention is never the correct choice for a child mourning a death
True- Lack of mourning or appearance of coping well on surface should never be taken at face value
What is a common finding in kids of all ages mourning the loss of a family member?
Loss of appetite
*Overt FTT is not common
True or False: Extracurricular activities like sports and music can help improve school performance
True
*But over-scheduling can have a detrimental effect
What is the goal with sibling rivalry?
Have siblings learn to resolve conflicts on own
*Parents need to step in with physical/verbal abuse, but goal is still to enable them to resolve conflicts on own
What are the 4 stages of grief reaction to a child with a disability?
- Shock/fear
- Denial/disbelief
- Sadness/anger
- Acceptance
What should you encourage for a parent of a child with a new disability?
Encourage contact and promote bonding to help work through fear
*Parents may require time to comprehend situation and mourn loss of “normal” child
What are 4 factors which are protective for siblings of kids with chronic disabilities?
- Larger family size
- Female/older siblings at higher risk for negative outcomes due to parentification
- Financial resources (help buffer negative impact)
- Intact families with harmonious relationships
What is one of the most important interventions to help families cope better when they have a child with disabilities?
Increase home resources
True or False: A mother and father responding differently to a child born with a disability is expected
True- No intervention necessary unless there is clear detriment to child
True or False: Kids who get a liver or kidney transplant typically don’t attain their genetic potential for adult height
True
What is a known problem for adolescents who have received transplant?
Poor compliance
What are 2 important psychosocial consequences that go along with organ transplant?
- Short stature
- Obesity
*Some of this is due to side effects of immunosuppressive medications
True or False: Parents who are health care professionals have to use home equipment cope better than non-health care professionals
False
True or False: Studies show that home monitors tend to increase parental hostility and depression
True
Although they are believed to have a role in apnea management in certain patient populations
What are the 4 categories for child abuse risk factors?
- External factors
- Parenting skills
- Vulnerability of the child
- Psychological factors
What other type of violence often occurs in addition to child abuse?
Domestic violence
True or False: Abuse may occur in foster care
True
Name 4 external factors which may increase the risk for child abuse
- Poor housing
- Multiple young children
- Social isolation
- Family discord
Name 4 parental skills factors which may increase the risk for child abuse
- Unwanted parenthood
- Unexpected parenthood
- Unrealistic expectations
- Parent abused as a child
Which 3 groups of children are at increased risk for being abused?
- Hyperactive
- Disabilities
- Premature
Name 6 psychological risk factors for child abuse
- Alcoholism in parents
- Drug abuse in parents
- Parental mental illness
- Parents who were abused as children
- Unrealistic expectations of the child
- Parental depression
What should you think if they tell you an injury was caused by sibling rivalry/siblings hitting each other?
Child abuse- This is rarely an explanation for serious injury
What are 3 features which aren’t important risk factors for child abuse?
- Gender of child
- Parental education
- Employment status
Name 2 infant feeding patterns which may reflect deeper mother/infant relationship problems
- Feeding child or infant to quiet them down
2. Propping bottle at bedtime
What is the most important intervention for infant feeding patterns such as feeding child or infant to quiet them down or propping the bottle at bedtime?
Psychosocial intervention (not addressing individual feeding issues)
True or False: Reporting any concern for abuse is absolutely mandatory in all 50 states
True
What needs to be considered for an unusual ingestion?
Abuse- Consider intentional if ingestion is unusual for child’s developmental stage (ex. infant ingesting alcohol- may be parent’s trying to sedate or stop infant from crying)
What is a somatization disorder?
Physical symptom that is unintentionally produced, but has no physiological explanation
Which children display more somatic symptoms?
When family member has a chronic physical illness
Which socioeconomic group has a higher rate of somatization?
Lower
What is conversion disorder?
Symptoms are incompatible with anatomical and medical logic
What is hypochondriasis?
Preoccupation with illness, frequently in context of previous illness
What is malingering?
Presenting with false or exaggerated symptoms, often with a motive
What is dysmorphic disorder?
Patient perceives themselves as being ugly or undesirable despite evidence to the contrary
What are somatic delusions?
Belief that something is medically wrong- may take on psychotic dimension (ex. pancreas has wings)
15 year old female, sudden loss sensation in left leg, can’t feel anything. No trauma, neuro signed off due to normal exam. Grandfather recently died natural causes, parents state she’s coping well and accepted death like an adult… best explanation for leg paralysis?
Conversion disorder (no such thing as a teen who has gone through a loss with no problems)
*Depression doesn’t explain physical findings
True or False: Psychosomatic illnesses (asthma, eczema, ect.) tend to be exacerbated during times of stress
True
*Avoid ordering excessive tests and studies with obvious psychosomatic illness or conversion disorder (this can reinforce perceived seriousness of symptoms)
What is recommendation for treatment of psychosomatic illness?
- Recognize and explain to family that symptoms are real, but there is no organic basis for them
- Address stress/anxiety that led to symptoms
- Positive feedback
- Remove secondary gain (like missing school)
What can be helpful for psychosomatic or conversion disorders which involve weakness?
Limited PT
Name 2 ways a child may react to stress
- Somatizing
2. Regressing
What is important for kids with somatization disorders (psychosomatic or conversion)?
Their perceived ability to have some degree of control over situation
What might be a clue to a somatization disorder?
Parental anxiety and how they are dealing with stress
How might children present with stress?
Somatic pain- Headache, chest pain, diarrhea, abdominal pain, fatigue, insomnia (fatigue and insomnia increase with age)
What is an important part of the history with recurrent abdominal pain?
Psychosocial history
What is the serious of chronic abdominal pain related to?
Interference with everyday life (missed days of school)
What should you consider with kids who have abdominal pain on school days which improves on weekends?
Psychosomatic
- School can be a factor in causing recurrent abdominal pain
- If pain persists on weekends, absence from school is unlikely to be a secondary gain factor
Name 6 of the known harmful effects of TV/Internet/Video Games on children
- Trivializing violence
- Blurring distinction between reality/fantasy
- Encouraging passivity at expense of activity
- Increased aggressive behavior
- Influences toys played with
- Influences cereals eaten
True or False: Screen time (including TV/Computer/Video Game) takes up more time than school
True
What is the only thing that exceeds the number of leisure hours spent on “screen time”?
Time sleeping
What is the recommended max amount of time for children >2 to watch TV?
2 hours/day, preferably with parents
What is recommended max amount of time for children <2 t watch TV?
None
True or False: During a normal sleep cycle, newborns sometimes experience arousal, but aren’t fully awake
True- Parents may mistake them to be awake and arouse them from sleep
By what age should infants be able to establish a day/night schedule?
2 months
What do you do for an infant who isn’t adjusting to a day/night sleep cycle?
Keep them awake more during the day so they will be more tired at night
By what age should an infant be capable of sleeping through the night?
4 months
How many hours a day should a 1 year old be sleeping
13-14
How should you put a baby to bed and why?
When they are sleepy, but awake- so they learn how to soothe themselves when awake and don’t become dependent on parents to go back to sleep when they arouse during the night
What is sleep training?
When parents let the baby cry before going back into the bedroom
At what age can parents start doing sleep training?
Between 4-6 months
What is common about nightmares and night terrors?
Child is agitated
At what point in the night do night terrors occur?
During the first third
Are night terrors genetic?
Unclear, but often there is a family history
Which gender experiences night terrors more frequently?
Boys
What is seen physically during a night terror?
Deep breathing, dilated pupils, sweating, tachypnea, tachycardia
What is source of injury during a night terror?
If the child becomes mobile- can hurt themnselves
What happens when a child awakens from a night terror?
They do not recall the episode
By what age do most children stop having night terrors?
By adolescence
What is the treatment goal for night terrors?
Make sure the environment is safe so they do not injure themselves
What can be done to break the cycle of night terrors?
Pre-waking the child before the time they usually have the night terror
True or False: Intervening during a night terror can be counterproductive and worsen the child’s agitation
True
At what time of night do nightmares occur?
During the last third of the night
What happens after a child wakens from a nightmare?
They can recall the nightmare (Often quite vividly)
Which can a child be woken easily from: A nightmare or night terror?
Nightmare
Are kids at risk for injury during a nightmare?
Not typically, they aren’t mobile and therefore at no real risk for physical injury.
What is the basis for sexual orientation?
Biology- Influence of adverse life events has not been substantiated
Homosexual teens/young adults are at higher risk for which 4 things?
- Substance abuse
- Suicide
- Dropping out of school
- Being homeless
Which is a choice…sexual orientation or sexual activity?
Sexual activity
True or False: Same sex experimentation (especially in early adolescence) is correlated with being homosexual as an adult
False- This is not a harbinger of homosexuality
When is sexual orientation determined by?
Mid-adolescence
True or False: There is no evidence for parental influence or various adverse life events causing homosexuality
True- There is growing evidence for the biological/genetic/hormonal basis for sexual orientation
What is a pediatricians role before a family pursues an international adoption?
Assist them in reviewing medical records (like information about the biological parents), anticipatory guidance
What is important to remember regarding medical records in an international adoption?
They may be inaccurate- take any medical history with a grain of salt
After an adoption, how long can the period of transition and attachment take?
Up to a year
What is recommended in terms of developmental screening for a newly adopted child?
Initial developmental assessment and re-check every 3-4 months during the first year
What is important to remember to do at the first visit for an adopted child?
Hearing and vision screening
In terms of immunizations, what should be done for an adopted child?
Attempt to verify immunization records
What testing is recommended for a newly adopted child?
CBC, lead level, HepB, HIV, syphilis
HepC (if child child is from an area endemic for HepC)
True or False: TB testing should be done for an adopted child regardless of whether or not they have received the BCG vaccination (Bacille Calmette-Guerin)
True
What should be done for a positive TB test in a child who got a BCG vaccination?
Needs to be addressed (CXR, ect) and not automatically attributed to the previous vaccine
True or False: Children in foster care use more mental and general healthcare resources when compared to others in the same socioeconomic strata
True
True or False: The AAP recommends the same screening and appointment guidelines for children in foster care as compared to their peers
False- AAP recommends kids in foster care receive more frequent routine evaluations than their peers
What do all kids entering foster care require?
Baseline behavioral, mental, and developmental evaluations
Who does the pediatrician need to communicate with to facilitate ongoing care for kids in foster care?
Directly with the caseworker (even after the child has been reunited with his/her family)
What is the primary goal of foster care?
Reunification of the child with his/her biological family
When is termination of parental rights and adoption considered for kids in foster care?
Only when reunification of the child with his/her biological family fails
What is vulnerable child syndrome?
When a parent exhibits anxiety over the child being more vulnerable than other children
What are features for parents of kids with vulnerable child syndrome?
- Overprotect child
- Don’t set age-appropriate limits on behavior
- Bring then to doctor (especially ED) for even minor ailments
Name 3 risk factors for vulnerable child syndrome
- History of serious illness or injury (even during the pregnancy)
- Child reminds parent of a special someone who died unexpenctedly
- Mother has history of threatened abortion, multiple spontaneous abortions, stillbirths, or fertility issues
What should you do if you identify risk factors for vulnerable child syndrome?
- Anticipatory guidance to prevent it
- Actively reassure regarding child’s normal health, growth, and development
- Regular scheduled appointments, then wean
- Watch what words you are using (ex. superinfection)
- Uncover source of parent’s anxiety (it is often subconscious)
What is factitious disorder/Munchausen Syndrome by Proxy?
When a child’s symptoms are created or invented by a caretaker (usually Mom)
When should you consider factitious disorder/Munchausen?
- Unexplained persistence or recurrence of symptoms
- Child appears healthier than history or labs indicate
- Symptoms are unusual to an experienced physician
- Symptoms don’t occur when child is separated from reporting caretaker
- Symptoms have only been witnessed by the perpetrator
- Reporting caretaker refuses to leave child’s side
- Negative workups don’t reassure the perpetrator
- Reported history is confusing and convoluted
- Child has been may doctors/sub-specialists without cause found for symptoms
True or False: Mom’s who inflict injuries in MSBP may suffer from Munchausen themselves and usually have a more extensive medical background than expected
True
What is usually noted in the history for Mom’s who inflict injuries in MSBP?
Emotional/physical abuse, neglect, drug/alcohol dependence, suicide attempts
What is the typical role for the father in MSBP?
Passive, distances himself from situation
True or False: In MSBP, physicians are usually responsible for most of the harm to children (even though they are trying to help) and most of harm occurs in the hospital
True
What is another name for MSBP?
Medical child abuse
What typically happens when the physician confronts the patient’s family in MSBP?
The parent removes the child from that provider’s care
What should be done if you suspect MSBP?
Gather all medical records and report case to CYS
What are two helpful things in determining if a child’s symptoms are due to MSBP?
- Remove child from parent to see if symptoms resolve
2. Videotaping visits in the hospital
What are kids who have MSBP at risk for?
Developing chronic invalidism (accept illness resulting in an inability to lead a “normal” life)
What do kids with MSBP require?
Long-term counseling
