Recall Deck 3 (2022) Flashcards
- ANXIETY: Selective mutism
a. What are 4 core features of selective mutism?
i. Failure to speak in expected social situations despite speaking in other situations, present for 1 month, functional impairment, not a language or knowledge issue.
b. What is the treatment of selective mutism?
i. CBT (systematic desensitization, systematic reinforcement of speech behaviour).
ii. Limited evidence but some respond to fluoxetine.
- ANXIETY: Sunday night abdominal pain, gets better by Monday afternoon.
a. What is the differential?
i. Generalized anxiety disorder, social anxiety disorder, separation anxiety, somatic symptoms disorder, rule out medical condition
b. What are 2 non-DSM criteria of separation anxiety (or was it criteria… just learn both the criteria and the “associated features” section) ***may not have been a question, review anyway
i. Criteria: developmentally inappropriate persistent, excessive fear of separation from attachment figure, 3+ of distress w/separation, worry about separation, worry about harm/loss of attachment, refusal to leave home, refusal to be alone, refusal to sleep, nightmares of separation theme, physical symptoms
ii. Associated features: social withdrawal, apathy, sadness, difficulty concentrating on work or play; fear of specific situations that are perceived as dangerous to attachment figure (eg. burglars, car accidents); homesickness or extremely uncomfortable when away from home; school refusal; academic difficulties; social isolation; angry or aggression towards someone who may be forcing separation; described as demanding, intrusive, in need of constant attention as children; dependent and overprotective as adults.
c. 3 specific strategies you would employ to reduce absenteeism:
i. Planned exposures, collaboration with school and family (eg. teacher aware, classroom set up), designated break space at school, psychoeducation around accommodation for family, reward system if youth interested
ii. Rule out other contributing challenges or barriers to school (eg. specific learning disorders, ADHD, etc.)
- CL: Kid with epilepsy and presenting with neuroveg shift (low mood, suicidal ideation, concentration, appetite change, insomnia).
a. What is your diagnosis?
i. Major depressive disorder, current episode, mod-sev.
b. Name 3 mental health conditions associated with epilepsy.
i. Major depressive disorder, generalized anxiety, ADHD, autism spectrum disorder, psychosis
ii. Bidirectional
c. What is the interaction with carbamazepine and fluoxetine?
i. Fluoxetine, inhibitor of CYP2D6 and to a lesser degree inhibiting CYP2C19, causes significant elevations in the plasma levels of a number of antiepileptic drugs (eg. phenytoin and valproate).
ii. Some case report suggest significant elevations of carbamazepine plasma levels with fluoxetine. Fluoxetine may also elevate the concentration of the carbamazepine toxic metabolite. Some studies have not reported on any clinically significant interactions between carbamazepine and fluoxetine.
- CULTURE: 16F immigrated from Jordan, coming in for first psychiatric assessment. What 5 cultural things would you assess/explore?
a. Cultural identity of the individual, cultural concepts of distress, psychosocial stressors and cultural features of vulnerability and resilience, cultural features of the relationship between the individual and the clinician, treatment team and institution
b. DSM5-TR: Cultural Formulation Interview – Cultural Definition of the Problem (questions 1–3); Cultural Perceptions of Cause, Context, and Support (questions 4–10); Cultural Factors Affecting Self-Coping and Past Help Seeking (questions 11–13); and Cultural Factors Affecting Current Help Seeking (questions 14–15); Clinician-Patient Relationship (question 16).
- DEPRESSION: DMDD question
a. Per DSM what are 2 things that cannot be co-diagnosed with DMDD:
i. Bipolar disorder, IED, ODD.
b. Per DSM what are 2 things that CAN be co-diagnosed with DMDD:
i. ADHD, MDD, CD, SUD.
ii. Straight out of DSM5-TR: “This diagnosis cannot coexist with oppositional defiant disorder, intermittent explosive disorder, or bipolar disorder, though it can coexist with others, including major depressive disorder, attention-deficit/hyperactivity disorder, conduct disorder, and substance use disorders.”
c. What are kids with DMDD they at risk for as adults?
i. Unipolar depressive disorder or anxiety disorder
- DEPRESSION: What, other than substance use, impulsivity, and psychiatric comorbidities are risk factors for acute suicidal ideation in adolescents? 5 things.
a. Indigenous, family history, previous suicide attempts, agitation, male, older age (16+)
- DEPRESSION: Bullying
a. What are 3 individual patient factors that increase SI risk after bullying?
i. Depression, anxiety, sleeping difficulties, eating disorders, school absenteeism, running away, substance use, non-suicidal self-harming
Demographic Factors
Being male - Males who are bullied tend to have a higher risk of suicidal ideation compared to females.
Younger age - Bullying victimization during early adolescence (ages 11-13) is associated with increased suicide risk.
Mental Health Factors
Pre-existing depression or anxiety disorders
History of previous suicide attempts
Substance abuse issues
Emotional distress and poor coping skills
Social/Environmental Factors
Lack of social support from family and peers
Coming from a single-parent family
Low socioeconomic status
Experiencing other forms of abuse (physical, sexual, etc.)
Family dysfunction or conflict
Unsafe school environment
Bullying-Related Factors
Being a bully-victim (both a bully and a victim)
Experiencing more severe or frequent bullying
Being cyberbullied in addition to traditional bullying
Feeling hopeless about the bullying situation
Other Risk Factors
Poor academic performance
Low self-esteem
Impulsivity or aggression
Belonging to a sexual minority group
b. Name 2 reasons you would call police for internet bullying
i. Exploitative content (eg. photos, written information)
ii. Sexually-inappropriate content (eg. age, consent)
iii. Threatening content to self or others (eg. individual, groups)
- DISRUPTIVE: Kid with ADHD and teacher gave a screening/rating scale and says has ODD. At home, okay except upset when doing homework. Plays competitive hockey and swimming.
a. What specific 3 questions do you ask hockey coach to figure out if they have ODD?
i. Affective (easily annoyed, loses temper, resentful), defiance (argues w/authority, refuses to comply, deliberately annoys others, blames others), vindictive/spiteful
b. Assuming collateral rules out ODD, what are 2 most likely diagnoses?
i. ADHD, specific learning disorder(s), parent-child relationship problem
- EATING: Eating disorders: bulimia
a. Name 3 risk factors for bulimia?
i. Family history, history of trauma, decreased self-esteem, social anxiety, depressive symptoms, childhood obesity/weight concerns, overanxious temperament.
b. Name 2 most common triggers for binge/ purge?
i. Negative affect, interpersonal stressors, boredom, body weight, dietary restraint.
*stress
*poor body image
- ECT:
a. 2 reasons o/s of Dx for ECT:
i. Acute SI, depression with psychotic features, treatment resistant depression; catatonia, multiple medication intolerances, prior favourable response to ECT, rapidly deteriorating physical status, or any of the above in pregnancy; pt preference; refractory mania, resistant psychosis, refractory OCD, Parkinson’s, refractory status epilepticus, NMS
b. 3 things you would do on assessment/prior to initiation of ECT
i. Psychiatric evaluation – interview, collateral, rating scales, Dx, severity, past treatments
ii. Physical exam & labwork – Eeg. CBC, TSH, LFTs, U/A, tox screen, +/- ECG, EEG, CT or MRI. F pts should get pregnancy testing.
iii. Cognitive assessment for memory (pre-treatment, post-treatment and 3-6 mo post-treatment)
iv. Informed consent
v. Second opinion
vi. Concurrent treatment – therapy, medications
- ELIMINATION: Enuresis in a 6-year-old who is having bed wetting at home 4x per week. Nervous about going to sleepover. No hx of not having enuresis.
a. What is one possible pathophysiology mechanism of enuresis?
i. No arousal to bladder distension.
ii. Uninhibited bladder contractions prior to enuresis
iii. Dysfxnal arousal system during sleep
iv. OSA assoc’d w/enuresis
v. Developmental immaturity including motor & language
vi. Excessive volume + detrusor muscle contraction; or retention + detrusor muscle contraction
b. What are 2 non Pharm treatments for eneuresis?
Psychoeducation & reassurance. ∅ punshiment, ∅ humiliation. Bathroom before bed, avoid drinking fluids or caffeine before bed. Assure access to toilet. Include child in morning or diaper clean up non-punitively. Reward for good behaviour (if sensitive child, be careful that failure could ↓ self-esteem).
Behavioural strategies better longer term – motivational Tx for 5-7yo who are not wetting the bed every night but >1/wk. Enuresis alarms (effective in Rx <50%, preventing relapse & LT, good for motivated older kids) – use if 14 consecutive dry nights; bell and pad, night alarms, routine/hygiene before bedtime; consider overlearning by drinking excessive fluids.
c. What are 2 Pharm treatments for eneuresis?
If going to sleepovers, needing rapid, short-term response (high relapse rate however) or behavioural Tx not effective, can use DDAVP (>5yo).
3rd line: TCAs (eg. imipramine) ↓ amount of time spent in REM sleep, stimulate vasopressin secretion, relaxes detrusor muscle).
- NEURODEVELOPMENTAL: Adolescent Kid with ID that behaves at baseline at a level of a 4 year old, history of not doing well at school. Presents with 4 day hx of fluctuating mood, lability, not sleeping well, and randomly screams. Given ativan and got worse.
a. What are 3 psychiatric differentials you’re considering apart from ID.
i. Substance use
ii. Catatonia
iii. Mood disorder – depression, bipolar
iv. Psychosis – brief psychotic disorder, schizophreniform disorder
v. Trauma – adjustment disorder, acute stress disorder
vi. More LT – specific learning disorder, language disorder, sleep disorder
- NEURODEVELOPMENTAL: Adolescent Kid with ID that behaves at baseline at a level of a 4 year old, history of not doing well at school. Presents with 4 day hx of fluctuating mood, lability, not sleeping well, and randomly screams. Given ativan and got worse.
b. Name 2 medical conditions that you would consider
i. Neurological – Seizures/epilepsy, encephalitis
ii. Pain syndromes
- NEURODEVELOPMENTAL: Person with winking/shrugging. Hx adhd + odd. On a stimulant. Had a grandpa with unknown neurological condition that recently passed away.
a. What are 3 differentials?
i. Tic disorder – provisional tic disorder, chronic motor tic disorder
ii. Stereotypic movement disorder
iii. Medication side effect
iv. Substance-induced
- NEURODEVELOPMENTAL: Person with winking/shrugging. Hx adhd + odd. On a stimulant. Had a grandpa with unknown neurological condition that recently passed away.
b. What is one investigation or strategy (both words were used) to figure out what it is?
i. Stop the stimulant (?unmasking of tics)
ii. Consider ruling out partial seizures w/EEG
- NEURODEVELOPMENTAL: Person with winking/shrugging. Hx adhd + odd. On a stimulant. Had a grandpa with unknown neurological condition that recently passed away.
c. What is one Pharm treatment you would use?
i. 1st line pharm: Guanfacine, clonidine
ii. 2nd line pharm: Risperidone, aripiprazole
- NEURODEVELOPMENTAL: Person coming in with math difficulties. What are 5 things on a psychoed that would suggest a learning disorder in math?
a. Not sure why this is a question on this exam… lemme just get my PhD in my spare time, see below for articles.
b. General answer probably: Deficits could be in basic mathematical computational skills, concepts, problem-solving, logical reasoning, fluency, mental calculation, visuospatial working memory
c. Calculation, fact retrieval, quantity processing, quantity-number linking, numerical relations, and visual-spatial short-term storage.
i. Haberstroh S, Schulte-Körne G. The cognitive profile of math difficulties: A meta-analysis based on clinical criteria. Frontiers in Psychology. 2022 Mar 11;13:842391.
e. Deficits in visuospatial and verbal WM deficits, deficits in cognitive control (problem-solving, decision-making), logical reasoning
i. Menon V, Padmanabhan A, Schwartz F. Cognitive neuroscience of dyscalculia and math learning disabilities.
- NEURODEVELOPMENTAL: Kid with refractory ADHD, not responding to meds. Recurrent episodes of falling asleep (actually teacher observed “sleepiness”) in class, daily.
a. Name 2 sleep disorders that could explain these symptoms
i. Obstructive sleep apnea
ii. Hypersomnolence disorder
iii. Narcolepsy
iv. Circadian-related
v. Medication-related
- NEURODEVELOPMENTAL: Kid with refractory ADHD, not responding to meds. Recurrent episodes of falling asleep (actually teacher observed “sleepiness”) in class, daily.
b. Name 3 symptoms that would connect the issues to the sleep disorders
i. Morning headaches, weight gain, snoring, snorting/gasping, pauses in breath, daytime sleepiness, unrefreshing sleep, tonsillar issues, large neck size, abnormal maxillary-mandibular anatomy
ii. Recurrent lapses into sleep within the same day, non-restorative night time sleep, prolonged main sleep episode >9h
iii. Cataplexy, lapsing into sleep or napping during the day,
- NEURODEVELOPMENTAL: 4 year old ADHD, really severe (climbing on things, running away from group, dysregulated and hits other kids). All over the place. Name 5 first line treatments.
a. Non-pharmacological 1st line – parent training, behavioural management, psychoeducation, environmental/educational accommodations, skills-based, mindfulness, relaxation techniques, individual therapy, family therapy, couples/marital therapy
- NEURODEVELOPMENTAL: ADHD 5 things that impact the interpretation of long term studies of psychostimulants in ADHD
a. Question not clearly defined – long term effect of being treated with ADHD medication OR cumulative effect of being treated for longer periods of time.
b. Confounding time-factors (eg. life events, episodes of disease) for starting or stopping treatment which can change risk of outcomes.
c. Time-to-event outcomes (eg. injuries, suicide attempts) measured with duration of treatment is dependent on length of follow-up.
d. Use of ADHD medication measured by filled prescriptions, only applies to patients who choose to fill prescriptions (misclassification of exposure and bias results, drug holidays).
e. Treatment assignment not masked for either patients or clinicians.
f. Data from one country/state/region, which may not be generalizable to other settings. Differences in diagnostic and treatment practices of ADHD.
- NEURODEVELOPMENTAL: Family of kid who tried numerous non-pharm treatments and failed. Family does not want meds. You assess + feel that patient has SEVERE ADHD, meds is only resort. What are 5 things you would tell them so they can make an informed decision?
a. Indications for medication with priority emphasis on functional skill development and safety
b. Indications for treatment of ADHD symptoms, both hyperactive-impulsive and inattentive
c. Side effects: appetite, sleep, emotional lability, effects on blood pressure and heart rate, unmasking of tics, small risk of suicidal ideation
d. Alternatives: stimulant vs. non-stimulant options, evaluation and treatment of other comorbidities
e. Expectations from role of medication
f. Longer term considerations: substance use, impulsivity, sexual encounters/risk of teen pregnancy; reduce risk of depression, anxiety, social challenges, school difficulties
- NEURODEVELOPMENTAL: Name 2 studies and results that look at the link between SUD and stimulant
a. Prepubertal youth that are on stimulants, appear to be less responsive to substances when taken post-puberty possibly.
b. Early stimulant treatment reduces or delays the onset of SUDs and perhaps cigarette smoking into adolescence; however, the protective effect may be lost in adulthood. [CADDRA]
c. Faraone, S.V. and T.E. Wilens, Effect of stimulant medications for attention-deficit/hyperactivity disorder on later substance use and the potential for stimulant misuse, abuse, and diversion. J Clin Psychiatry, 2007. 68 Suppl 11: p. 15-22. 135.
d. Molina, B.S. and W.E. Pelham Jr, Childhood predictors of adolescent substance use in a longitudinal study of children with ADHD. J Abnorm Psychol, 2003. 112(3): p. 497-507.
e. Molina BS, Flory K, Hinshaw SP, et al. Delinquent behavior and emerging substance use in the MTA at 36 months: prevalence, course, and treatment effects. J Am Acad Child Adolesc Psychiatry. 2007;46(8):1028–1040
f. Riggs, P.D., et al., Randomized controlled trial of osmotic-release methylphenidate with cognitive-behavioral therapy in adolescents with attention-deficit/hyperactivity disorder and substance use disorders. J Am Acad Child Adolesc Psychiatry, 2011. 50(9): p. 903-14.
g. Wilens, T.E. and N.R. Morrison, The intersection of attention-deficit/hyperactivity disorder and substance abuse. Curr Opin Psychiatry, 2011. 24(4): p. 280-285.
h. Wilens, T.E., et al., An open study of adjunct OROS-methylphenidate in children and adolescents who are atomoxetine partial responders: I. Effectiveness. J Child Adolesc Psychopharmacol, 2009. 19(5): p. 485-92.
- NEURODEVELOPMENTAL: ASD assessment.
screening tool for ASD in infants
i. Modified Checklist for Autism in Toddlers Revised with Follow-up Questions (M-CHAT-R/F) for initial screening in children 16-30mo.
b. Three SCREENING tools for asd in CHILDREN?
i. Social Communication Questionnaire (SCQ) 4yo +
ii. Social Responsiveness Scale (SRS) 18mo +
iii. Autism Spectrum Quotient (AQ) 4yo +
iv. Autism Spectrum Screening Questionnaire (ASSQ) 7-16yo
c. What is the GOLD STANDARD DIAGNOSTIC INTERVIEW for asd?
i. Autism Diagnostic Observation Schedule (ADOS)
ii. Autism Diagnostic Interview Revised (ADI-R)
- NEURODEVELOPMENTAL: Kid with ASD. Struggles with pragmatic language and social reciprocity.
a. What are two elements of ASD ABA helpful for other than problem behaviours?
i. Increase language and communication skills
ii. Improve attention, focus, social skills, memory, and academics
b. 3 other evidence based skills for developing social emotional reciprocity and language skills in ASD kids/youth?
c. What 3 interventions would you suggest for addressing pragmatic language, social reciprocity?
- OCD – kid still has symptoms on 200 of sertraline. Previously failed trial of escitalopram. Mom thinks it’s too high (she’s on lower dose of sertraline). They do genetic testing.
a. What are the pharmacokinetics of SSRI that are different in children vs adults?
i. ↑ hepatic capacity, ↑ GFR, ↓ fatty tissue, ↑ dose to weight ratio vs adults, faster elimination of drug
ii. Relatively higher volume of distribution of water-soluble drugs in pediatric pop vs adulthood
Genetic variations that impact SSRI metabolism may have a more pronounced effect in pediatric patients
b. What would you find on genetic testing report that would impact sertraline efficacy?
i. Rapid 3A4 metabolizer
c. What would your next step with meds be and explain why?
i. Higher dose of sertraline
ii. Augmentation with antipsychotics
a. OCD– 2 of the most common obsessions?
i. Contamination, aggression (harm), sexual, and somatic obsessions, and excessive scruples/guilt (religiosity)
b. 2 of the most common compulsions in OCD?
i. Washing, repeating, checking, and ordering are the most commonly reported compulsions
c. Name 1 FDA approved med for ocd in kids
Clomipramine
- What are 3 possible risk factors associated with social media use and SI/NSSI?
a. Cybervictimization, cyberbullying perpetration, SI/NSSI-related social media use, problematic use, and sexting
b. Name 2 immediate reactions to violence in media with youth.
i. Primes existing aggressive scripts and cognitions
ii. Increases physiological arousal
iii. Triggers an automatic tendency to imitate observed behaviors
iv. LT effects via several types of learning processes leading to the acquisition of lasting (and automatically accessible) aggressive scripts, interpretational schemas, and aggression-supporting beliefs about social behavior, and by reducing individuals’ normal negative emotional responses to violence (i.e., desensitization).
- Teenage, diabetes, recurrent admissions/ER presentations with DKA.
a. What is the most common part of the diabetic regimen they don’t follow?
Blood glucose monitoring is the most common part of the diabetic regimen that teens dont follow
b. What are 2 negative factors influencing adherence with teenager with diabetes?
i. Depression, eating disorders, lower SES, lower family support, higher family conflict
ii. Developmental behaviors, flux in family dynamics, and perceived social pressures, which compound the relative insulin resistance brought on by pubertal physiology
concerns about body image
developmental behaviours
flux in family dynamics
perceived social pressures
c. What are 2 positive factors influencing adherence with teenager with diabetes?
i. Insight, resilience, family and/or peer support
d. What are 2 strategies to improve adherence in teenager with diabetes?
i. Encouraging nonjudgmental family support in the daily tasks of blood glucose monitoring and insulin administration, motivational interviewing and problem-solving techniques, flexibility in dietary recommendations, and extending provider outreach and support with technology
- PHARMACOLOGY: Kid poor response with anxiety and experiencing side effects with minimal improvement. Two modes of changing meds? What are 3 adverse effects of switch of meds?
a. Switch or cross taper medications
b. Consider alternative SSRI or SNRI
c. Potential for withdrawal symptoms if short-acting medication, additive side effect profile, no guarantee of efficacy of new medication
- PSYCHOTHERAPY: Name 2 differences between IPT-A vs IPT in adults. List one of the 3 phases of a role dispute in IPT.
a. IPT-A vs IPT adults – parents can be involved for psychoeducation and to work on any relationship challenges with their youth; developmentally appropriate –> 1. fewer number of sessions (12 instead of 16-20), 2. parents involved, 3. sick role is more limited in IPT-A
b. Phases of a role dispute – renegotiation, impasse, and dissolution (recognize own feelings about what they want/don’t want, feelings about the relationship and the other person, and what might constitute a reasonable compromise)
- PSYCHOTHERAPY: Name 5 things you do as a group facilitator for parents of youth with mental health challenges – Yalom’s group therapy
a. Group cohesion, ventilation, insight, inspiration, reality testing, altruism, contagion, empathy, imitation, interpretation, learning
- PSYCHOTHERAPY: * List 2 things that parenting intervention could do for parents?
a. Self-regulation, attachment
b. Think circle of security, the incredible years
- SCHIZOPHRENIA: 5 symptoms that differentiate mania with psychosis vs schizophrenia?
a. Psychotic symptoms only during mood episode
b. Decreased need for sleep
c. No alogia, avolition, anhedonia
d. Euphoric mood
e. No prodromal period for mania with psychosis
- SCHIZOPHRENIA: Cannabis + psychosis.
a. What are 3 scientific based facts about cannabis and psychosis?
i. RFs for psychosis include younger age of onset of cannabis use, regular use doubles risk of chronic psychotic disorder, strong association between <15yo use and psychotic disorder, cannabis use associated with increased relapse rates, hospitalizations and positive symptoms in psychotic pts
b. Name 2 pharmacokinetics or pharmacodynamic properties about cannabis?
i. Lipid-soluble and poor bioavailability
ii. Pharmacokinetics of cannabinoids and the effects observed depend on the formulation and route of administration (eg. peak plasma concentrations more rapidly achieved with inhalation than ingestion).
iii. Both THC and CBD metabolized by liver (2C9, 2C19, 3A4)
- SCHIZOPHRENIA: Chinese kid, treatment resistant schizophrenia, age 10. Want to start Clozapine.
a. One risk factor that would make this patient more susceptible to agranulocytosis.
i. Decreased 2D6 activity = slow metabolism = higher levels of clozapine sustained = higher risk of agranulocytosis
b. 3 side effects of clozapine that are worse in kids
i. Neutropenia/agranulocytosis, lowering of seizure threshold, tachycardia, EPS
c. Fever, dyspnea, myalgia in an asian kid on clozapine- what do you think is going on?
i. Myocarditis – get baseline ECG, CRP, troponin, call cardio if any instability
- SCHIZOPHRENIA: Childhood schizophrenia: Name 3 (or 5?) cognitive deficits in children with schizophrenia. Name one positive or negative symptom that would be present in early childhood.
In general, ↓ memory, ↓ attention, ↓ executive dysfxn. More specifically, declarative memory, working memory, language fxn, executive fxn, processing speed, abN sensory processing, attention and inhibitory capacity. ↓ overall brain volume.
Less elaborate delusions or hallucinations, visual hallucinations more common, nonspecific emotional-behavioral disturbances and psychopathology, intellectual and language alterations, and subtle motor delays.
- SLEEP: Restless leg syndrome
a. Name 3 symptoms:
i. Urge to move legs, usually accompanied by/in response to uncomfortable & unpleasant sensations in legs by all of urge to move legs: (1) begins or worsens during periods of rest/inactivity, (2) partially or totally relieved by mvmt, (3) worse in evening or at night than during day or occurs only in evening or night.
b. Name 2 Pharm treatments for restless leg syndrome:
i. Iron supplementation, clonidine, clonazepam, gabapentin
- SOMATIC: Factitious disorder
a. Name 2 core criteria for factitious disorder by proxy?
i. Falsification of physical/psychological sx or signs or induction of injury/dz in another asso’d w/identified deception. Presents victim asill/impaired/injured. Deceptive behaviour in absence of obvious external rewards.
b. Name 3 things if you don’t intervene that the youth is at risk for, psychologically , from factitious disorder by proxy
Personality disorder, depression, SUD, anxiety. Mortality.
- attachment injury/rupture–> may have trouble forming healthy relationships later in life
- PTSD/trauma disorders related to medical and parental treatment
- difficulties with reality testing later in life
- anxiety disorders–> in particular anxiety around health care
- problems with self esteem and identity formation–> may result in depression, personality disorders and relational problems
- mood disorders i.e MDD
- somatic symptom disorders
- SUICIDE: 5 strategies you would give a youth that presented to ER to scale back cutting (they cannot do therapy right away so immediate strategies to take home that day)
a. TIPP – temperature, intense exercise, paced breathing, progressive muscle relaxation
b. Alternative strategies – ice cube, elastic band
- PSYCHOTHERAPY: 16 chronic SI + SH, several recent presentations to ER (?brief admissions). Seeing them in your OFFICE.
a. What is the most important thing to assess?
i. Safety, limits of confidentiality
- PSYCHOTHERAPY: 16 chronic SI + SH, several recent presentations to ER (?brief admissions). Seeing them in your OFFICE.
b. You decide to refer to DBT. What are two “modalities” of DBT?
i. DIME – distress tolerance, interpersonal effectiveness, mindfulness, emotional regulation
- PSYCHOTHERAPY: 16 chronic SI + SH, several recent presentations to ER (?brief admissions). Seeing them in your OFFICE.
c. What are two treatment goals of DBT?
i. Behavioural control from life-interfering behaviours
ii. Emotional experiencing
iii. Building a life worth living
- TRAUMA: Kid with flat affect, hx trauma, hx neglect, not responding to comfort (RAD description).
a. What is this? 2 differential?
i. Reactive attachment disorder, acute stress disorder, post-traumatic stress disorder, major depressive disorder, malnutrition
- TRAUMA: Kid with flat affect, hx trauma, hx neglect, not responding to comfort (RAD description).
b. 2 treatments for this?
i. Secure attachment – consistency with primary caregiver
ii. Rule out neglect. Treatment of co-morbidities.
- TRAUMA: Trauma in 5 year old, comparing child vs adolescent PTSD sx.
a. What is one difference in trauma symptoms for re- experiencing?
i. Re-enactment, repetitive play
- TRAUMA: Trauma in 5 year old, comparing child vs adolescent PTSD sx.
b. What is one difference in trauma symptoms in mood/ cognition?
socially withdrawn behaviours
- TRAUMA: Trauma in 5 year old, comparing child vs adolescent PTSD sx.
c. What is one difference in hyperarousal?
more vague nightmares
developmental regression
- TRAUMA: Trauma in 5 year old, comparing child vs adolescent PTSD sx.
d. What are 2 component of TF-CBT?
i. Key elements of the intervention include psychoeducation (e.g., common reactions to trauma exposure), coping skills (e.g., relaxation, feelings identification, cognitive coping), gradual exposure (e.g., imaginal, in-vivo), cognitive processing of trauma-related thoughts and beliefs, and caregiver involvement (e.g., parent training, conjoint child-parent sessions).
ii. Developmental considerations in reducing PTSD symptoms: the role of the caregiver and the developing nature of a child’s emotion regulation and coping capabilities.
a. What are 2 meds with some evidence preventing PTSD?
i. None? Consider propranolol and morphine based on Esther’s notes but not great evidence. Cochrane review suggests that evidence is not good enough to recommend propranolol.
*controlling pain prevents PTSD in pediatric burn victims
*per PARENT REPORT, SSRIs might prevent PTSD in pediatric burn victims
*lecture notes: maybe beta blockers and/or alpha agonists may reduce hyperarousal and reduce neurokindling effect if used early in symptom onset but these are open trials
b. What alpha agonist has evidence for imsomnia/nightmares in PTSD?
i. Prazosin
c. What class of med has evidence to treat PTSD?
i. None in kids technically (sertraline is not recommended)? SSRIs in adults.
“In summary, while some medications may be used to treat PTSD symptoms in children in certain cases, there is currently no strong positive evidence supporting any specific medication as a primary treatment for pediatric PTSD. Psychotherapy, especially TF-CBT, remains the most evidence-based and recommended approach for treating PTSD in children and adolescents.”
- TRAUMA: Kid who was reared in institutionalized care (numerous foster homes, etc)?
a. What are 2 brain structures you would expect to be impacted?
i. Limbic, frontostriatal pathways?
ii. Reduction of grey matter volume in the prefrontal cortex, hippocampus and cerebellum?
- smaller cortical grey matter volumes–> especially insula, parietal cortex
- impaired white matter integrity
- smaller PFC and cerebellum
- altered EEG activity
- likely some changes in amygdala and hippocampus but these findings are less reliable
- TRAUMA: Kid who was reared in institutionalized care (numerous foster homes, etc)?
b. 4 cognitive long term impacts?
i. Lower IQ, decreased working memory
ii. Reduced physical growth, poor executive skills, emotion dysregulation, elevated symptoms of attention-related disorders
- TRAUMA: Kid who was reared in institutionalized care (numerous foster homes, etc)?
c. 1 endocrine change in youth with long term institutionalization?
i. Lower overall levels of vasopressin and, after interactions with their caregivers, lower levels of oxytocin than never institutionalized comparison children
ii. Higher levels of cortisol when interacting with their mothers than with unfamiliar adults; more severe early neglect was associated with the highest basal cortisol levels.
*?HPA axis abnormalities related to ACEs
- TRAUMA: Kid whose arm was cut off in accident. What has the most evidence based treatment for PTSD in childhood?
a. Psychotherapy: TF-CBT
