Recall Deck 4 (2021)

Question 1

Fragile X name the gene

Answer 1

FMR1 gene

Question 2

FASD name the neurocognitive

Answer 2

–?Other Specified Neurocognitive Disorder–Neurocognitive disorder related to prenatal exposure to alcohol.
–FASD neurocognitive symptoms: lower overall intelligence and deficits in executive functioning, learning and memory, language, visual-spatial functioning, and attention.

Question 3

FASD name the self-regulation issue:

Answer 3

–Individuals who struggle with self-regulation find it challenging to regulate their thoughts, feelings, and behavior effectively. This can manifest in several ways for individuals with FASD, including difficulties with:

1. Task Completion: Individuals may struggle with staying focused and completing tasks, often becoming easily overwhelmed or distracted.
2. Flexibility: Adapting to changes in routines or unexpected situations can be challenging, leading to frustration or resistance.
3. Planning and Organization: Difficulties in planning, organizing, and sequencing steps can hinder individuals’ ability to effectively navigate daily tasks and activities.
4. Sensory Sensitivity: Individuals may struggle with sensory processing, finding it challenging to filter out irrelevant sensory information and focus on the task at hand. Background noise, bright lights, or other environmental stimuli can be overwhelming and distracting.

Question 4

FASD name the adaptive function issue

Answer 4

–The area of adaptive function most affected by prenatal alcohol exposure appears to be social functioning.
–Research indicates that adolescents and adults with FASD have the adaptive
skill functioning of a 7-year-old (84). Other research suggests that individuals
with FASD and individuals with intellectual disabilities have comparable
levels of adaptive functioning (84,20). Further, relative to children with
ADHD, children with FASD do not improve with time in the area of
adaptive skills (85). In fact, research indicates that adaptive deficits worsen
as a child matures into adolescence and adulthood (20,84-88) which may
be the result of limited frontal lobe development during childhood (24,89).

Question 5

16 year old girl with BPD, impuslivity. Presents with mood, lability, confusion, sudden onset. List possible medical causes:

Answer 5

–substance or alcohol intoxication
–substance or alcohol withdrawal
–traumatic brain injury
–delirium
–metabolic derangement i.e hyponatremia, hypocalcemia
–epileptic activity/post ictal
–encephalitis
–autoimmune encephalopathy
–medication induced i.e steroid
–diabetic ketoacidosis
–CVA (less likely)

Question 6

Diff between asd and social anxiety

Answer 6

–Difference tends to be in SOCIAL MOTIVATION–> those with social anxiety tend to have social motivation but anxiety prevents them from being social, whereas a feature of some presentations of autism is a reduction in social motivation.
–also differences in physical manifestations i.e symptoms of anxiety (increased HR etc) in social anxiety vs stereotypies/repetitive behaviours/self stim in ASD.
–ASD has restricted interests, repetitive behaviours and sensory sensitivities

Question 7

What other criteria other than dsm 5 for seperation anxiety

Answer 7

The way this question is worded doesn’t make sense.
–ICD-10?
–children’s separation anxiety scale?

Question 8

What child adverse event from ECT

Answer 8

TARDIVE/PROLONGED SEIZURES MORE LIKELY IN ADOLESCENTS COMPARED TO ADULTS

From the JAACAP practice parameter quoted below:
“Adverse effects of ECT may include impairment of memory and new learning, tardive seizures, prolonged seizures, and risks associated with general anesthesia. In adults, the fatality rate associated with ECT is 0.2 per 10,000 treatments and the anesthesia-related mortality rate is 1.1 per 10,000. Adolescents are not believed to be at additional risk from ECT, nor are they are at increased risk of anesthesia-related complications in the immediate recovery period.
Tardive seizures are a rare but potentially serious side effect. These usually are encountered in adolescents who have a normal EEG before treatment and are not receiving seizure-lowering medications during treatment. Seizures that last longer than 180 seconds are considered, by convention, to be prolonged seizures. A prolonged seizure can be effectively terminated with additional methohexital, diazepam, or lorazepam. Prolonged seizures are clinically significant because they are associated with greater postictal confusion and amnesia and inadequate oxygenation, resulting in increased hypoxia-related risks (cerebral and cardiovascular complications). Appropriate medical consultation should be considered if difficulties are experienced in terminating a prolonged seizure, if spontaneous seizures occur, or if neurological or other physical sequelae appear to be present. In such cases, ECT should be resumed only after the assessment of treatment risks and benefits.
Other minor side effects include headache, nausea, vomiting, muscle aches, confusion, and agitation. These usually do not persist beyond the day of the treatment. Some of these are secondary to the anesthetic and some are secondary to the ECT treatment itself. These should be managed conservatively.”

The side effects of ECT described in adolescents include transient memory impairments, prolonged seizures (more frequent in adolescents than in adults), tardive seizures, and other benign and transitory effects (e.g., headache, confusional states, nausea, muscular pains) (65, 66, 67, 68, 69, 70).

Question 9

Indications for ect child based on practice parameters

Answer 9

Basically, the practice parameter indications for ECT in teens can be summed up by three requirements: 1. Diagnosis, 2. Severity of symptoms and 3. Lack of treatment response.

ECT may be considered when there is a lack of response to two or more trials of pharmacotherapy or when the severity of symptoms precludes waiting for a response to pharmacological treatment.

Mood disorders have a high rate of response to ECT (75%–100%), whereas psychotic disorders have a lower response rate (50%–60%).

This practice parameter “does not address the use of ECT in preadolescent children because of insufficient data and clinical experience.”

Before an adolescent is considered for ECT, he/she must meet three criteria:
* 1
Diagnosis: Severe, persistent major depression or mania with or without psychotic features, schizoaffective disorder, or, less often, schizophrenia. ECT may also be used to treat catatonia and neuroleptic malignant syndrome [MS].
* 2
Severity of symptoms: The patient’s symptoms must be severe, persistent, and significantly disabling. They may include life-threatening symptoms such as the refusal to eat or drink, severe suicidality, uncontrollable mania, and florid psychosis [MS].
* 3
Lack of treatment response: Failure to respond to at least two adequate trials of appropriate psychopharmacological agents accompanied by other appropriate treatment modalities. Both duration and dose determine the adequacy of medication trials. It may be necessary to conduct these trials in a hospital setting. ECT may be considered earlier in cases in which (a) adequate medication trials are not possible because of the patient’s inability to tolerate psychopharmacological treatment, (b) the adolescent is grossly incapacitated and thus cannot take medication, or (c) waiting for a response to a psychopharmacological treatment may endanger the life of the adolescent [MS].

Question 10

ODD treatment parenting

Answer 10

For kids age 8 and under, recommendation is for PARENT MANAGEMENT TRAINING (i.e Parent-Child Interaction Therapy, Positive Parenting Program). Consider a Multicomponent treatment (i.e Incredible Years, Dinosaur School Program)

For kids above age 8, recommendation is for FAMILY THERAPY i.e Brief Strategic Family Therapy, MULTISYSTEMIC THERAPY, Functional Family Therapy. Also consider addition of individual therapy such as CBT, Coping Power Program, Problem Solving Skills Training.

Multisystemic therapy has the most evidence is an intensive intervention with the youth and family, over the course of 4 months, with multiple interactions per week in difference settings. Interventions include: social skills, CBT, parent management training, school supports, peer group, neighbourhood supports and pharmacotherapy.

Negative evidence for group therapy.

Question 11

Adverse effects of risperidone

Answer 11

–hyperprolactinemia
–metabolic effects: weight gain, insulin resistance
–EPS
–tardive dyskinesia
–headache
–GI upset
–sedation
–blurred vision

Question 12

Lithium metabolism and distribution

Answer 12

–faster rate of clearance in kids, shorter elimination half life when compared to adults
–undergoes no metabolism by the liver and is excreted by the kidneys in urine
–amount eliminated is directly proportional to serum concentration
–approx 80% of lithium excreted undergoes reabsorption in the proximal tubule

Question 13

Med for weight gain in AN

Answer 13

–Olanzapine (may be particularly helpful in binge-purge type)

Question 14

Med group not used in AN (name 2)

Answer 14

–stimulants (reduced appetite)
–buproprion (reduced seizure threshold)
–TCAs (seizure risk)
–MAOIs

Question 15

AN psychotherapy treatment

Answer 15

–Maudsley Family Therapy
–Family Based Treatment
–CBT-E

Question 16

Stimulant wihtdrwal sx

Answer 16

–Dysthymic mood
–Vivid, unpleasant dreams
–fatigue
–insomnia or hypersomnia
–increased appetite
–psychomotor agitation or retardation

Question 17

Treatment for grief 9-year-old boy lost father suddenly due to motor vehicle collision. What do you tell mother who comes to ask you. What is the best for bereavement?

Answer 17

see card later in deck

Question 18

Parent factors exacerbating ocd

Answer 18

–accommodation –> i.e facilitating or performing rituals for the child, engaging in avoidance or supporting theirs child’s avoidance, providing reassurance for obsessions/compulsions, minimizing exposure to triggers, overprotectiveness

Question 19

Three categories of OCD symptoms and 3 comorbidities

Answer 19

Symptoms:
Obsessions
–Sexual
–Aggressive
–Contamination
–Hoarding/Saving
–Magical thoughts/superstitious
–Somatic
–Religious/Scrupulosity
–Miscellaneous

Compulsions
–Checking
–Washing/Cleaning
–Repeating
–Ordering/Arranging
–Counting
–Hoarding/Saving
–Excessive games/superstitious behaviours
–Rituals involving other people
–Miscellaneous

Comorbidities:
–anxiety (76%)
–mood (63%)
–somatoform d/o
–BDD
–OCPD
–SUD
–psychotic d/o (12%)
–bipolar d/o (10-20%)
–tics (30%)
–ODD
–trichotillomania
–excoritation
–AN/BN

Question 20

Treatment of aggression ASD

Answer 20

Risperidone, aripiprazole; behavioral

Question 21

RAD vs autism

Answer 21

While Attachment Disorder and Autism may share some behavioral similarities, there are distinct characteristics that can help parents differentiate between the two:
1. Social behavior: Children with Attachment Disorder typically show difficulties in forming close emotional bonds, but they can still engage in reciprocal social interactions. In contrast, children with autism may struggle with understanding and initiating social interactions.
2. Response to caregivers: Children with Attachment Disorder may exhibit a lack of emotional responsiveness to caregivers but can still form attachments, albeit insecure ones. Children with autism might seem disinterested or disconnected from caregivers but may not necessarily display the same lack of emotional responsiveness.
3. Communication patterns: Children with autism may experience significant challenges in language development and communication, while those with Attachment Disorder may have age-appropriate communication skills despite their emotional challenges.
4. Repetitive behaviors: While both conditions can involve repetitive behaviors, these behaviors serve different purposes. In Attachment Disorder, they may be a result of anxiety or fear, while in autism, they are often self-stimulatory and comforting.

Clinicians assessing children with autism are sometimes faced with a dilemma, especially if there is a definite or suspected history of abuse or neglect: is this autism or attachment disorder? This is important because the attachment disorders (reactive attachment disorder and disinhibited social engagement disorder) are thought to be caused by abuse or neglect, whereas autism is not. We discuss the Coventry Grid, a clinical tool aiming to aid differentiation between autism and attachment disorders.
There were certain symptoms that, in this sample, only occurred in those with autism (even if the child also had RAD/DSED): these were ‘restricted and obsessive interests, repetitive stereotyped play (e.g. lining up objects), stereotypies (e.g. hand flapping and spinning), craving movement (e.g. excessive running, jumping, and swinging), distress with crowds, fascination with repetitive movements (e.g. fans), picky eater (limited food preferences and/or hypersensitivity to food texture), normal motor and delayed speech milestones, and unusual fears (e.g. elevators, tornadoes, and small spaces)’ (Mayes Reference Mayes, Calhoun and Waschbusch2017).
BOX 2 The eight domains of the Coventry Grid
1. 1 Flexible thinking and behaviour
2. 2 Play
3. 3 Social interaction
4. 4 Mind reading
5. 5 Communication
6. 6 Emotion regulation
7. 7 Executive function
8. 8 Sensory processing

Question 22

Fragile x, what type of genetic

Answer 22

trinucleotide repeat in FMR1 gene, CGG

Question 23

3 associated conditions with Fragile X

Answer 23

ADHD
ID
ASD

–speech, language delay
–motor delay
–sensory processing disorders
–medical concerns like low muscle tone, macroorchordism, flexible joints

Question 24

Type of ADHD associated with epilepsy

Answer 24

–predominantely inattentive presentation more common in those with epilepsy (compared to combination type being the most common in the general population)

Question 25

2 patient factors that may make it hard for ADHD treatment for epilepsy

Answer 25

Traditional approach has been to consider that there is a higher risk of seizures with stimulants in those with epilepsy, which appeared to be dose dependent. However, more recent data suggests that this is not the case on a population basis and that stimulants can be used safely in those with epilepsy.

There may be other neuropsychiatric sequelae of epilepsy that can mimic ADHD, and thus it can be challenging to determine the source of challenging behaviours and/or symptoms in this case??

The diagnosis of ADHD can be challenged in some seizure types, such as CAE. Up to two-thirds of CAE patients can have comorbid ADHD [139]. Patients with controlled CAE can develop cognitive defects and variable levels of inattentiveness secondarily to impaired consciousness, resembling ADHD.

Perhaps consider other meds which have dual activity like Keppra, carbamazepine, topiramate.

MPH can increase serum phenytoin concentrations. Need to consider drug interactions. Carbamazepine is a very dirty drug.

Question 26

2 factors for meds for ADHD.

Answer 26

This is very vague lol…. Age? Ability to take pills? Need to sprinkle? Side effect concerns? Family history of response?

Question 27

3 things for reading disorder and 2 Comorbidities

Answer 27

This is also vague—3 symptoms of reading disorder?
Impairments in word reading accuracy, reading rate/fluency and/or reading comprehension.

Comorbidites can include (for all SLDs): ADHD, communication d/o, DCD, ASD, anxiety, depressive disorder, bipolar disorder.

Question 28

Elements of mindfulness

Answer 28

non-judgmental attention on the present moment

Mindfulness is a practice that involves cultivating a particular kind of awareness and attitude towards one’s experiences. It is often defined as the awareness that arises from paying attention, on purpose, in the present moment, and non-judgmentally. This definition highlights the core elements of mindfulness, which can be broken down into three main components:
1. Intention: This involves the conscious decision to cultivate mindfulness. It is about setting the purpose and motivation for being mindful, which guides the practice. Intention acts as the driving force behind the practice, helping individuals to stay committed and focused on being present.
2. Attention: Mindfulness requires directing one’s attention to the present moment. This involves observing thoughts, feelings, and sensations as they arise, without getting caught up in them. Attention in mindfulness is about being aware of the current experience and sustaining focus on it, which helps in recognizing mental events as they occur.
3. Attitude: The attitude with which mindfulness is practiced is crucial. It involves approaching experiences with an open, curious, and non-judgmental mindset. This means accepting things as they are without trying to change them, and being kind and compassionate towards oneself and others. This attitude helps in reducing reactivity and promotes a more peaceful and accepting way of being.
These elements work together to transform how individuals relate to their thoughts and experiences, fostering a more present and less reactive way of living. Mindfulness can be practiced through various techniques, including meditation, which further enhances these elements and supports overall well-being.

Question 29

Contrast mindfulness with relaxation

Answer 29

Definitions and Focus:
Relaxation refers to a state of being free from tension and anxiety, typically achieved through techniques that aim to reduce physical and mental stress. The focus is on calming the body and mind.Mindfulness, on the other hand, is the practice of being aware and fully present in the current moment without judgment. It involves paying attention to your thoughts, feelings, bodily sensations, and surrounding environment.

Intentions and Approaches
Relaxation:
* Aims to reduce tension and induce a calm state
* Uses techniques to change or alleviate stress and discomfort
* Focuses on pleasant or soothing experiences
Mindfulness:
* Aims to increase awareness of the present moment
* Teaches acceptance of current experiences, including discomfort
* Focuses on observing all experiences without trying to change them
Physiological Effects
Relaxation techniques primarily activate the parasympathetic nervous system (the “rest and digest” response), reducing physical signs of stress.Mindfulness can also lead to relaxation as a byproduct, but its effects are more centered on cognitive and attentional processes.
Outcomes and Applications
Relaxation:
* Primarily used for stress reduction and anxiety management
* Often employed for immediate relief of tension
Mindfulness:
* Used for a broader range of psychological and physical health benefits
* Can lead to long-term changes in cognitive patterns and emotional regulation
* Applied in various clinical settings, including stress reduction, depression treatment, and pain management

Question 30

b. Contrast mindfulness with CBT

Answer 30

Key Differences
* Approach to Thoughts and Emotions
* CBT: This therapy focuses on identifying and challenging negative thought patterns and beliefs, with the aim of changing them to improve emotional regulation and develop personal coping strategies. It involves a process called cognitive restructuring, where individuals learn to dispute distorted cognitions and replace them with more realistic thoughts.
* Mindfulness: In contrast, mindfulness-based approaches emphasize accepting thoughts and emotions without judgment. The focus is on observing thoughts and feelings as they arise, without attempting to change them. This practice fosters a non-reactive awareness of the present moment.
* Goal Orientation
* CBT: Typically, CBT is goal-oriented, with specific objectives set at the beginning of therapy. Clients work actively towards achieving these goals throughout the treatment process.
* Mindfulness: Mindfulness practices, on the other hand, cultivate an attitude of non-striving. While clients may seek mindfulness-based therapy for similar reasons as CBT, the process involves less emphasis on achieving specific goals and more on developing a mindful awareness.
* Therapeutic Techniques
* CBT: Utilizes a variety of techniques, including thought monitoring, cognitive rehearsal, and activity scheduling, to help individuals manage their symptoms by altering their thought processes and behaviors.
* Mindfulness: Techniques in mindfulness-based therapies include meditation, breathing exercises, and body awareness practices. These are designed to enhance awareness and acceptance of the present moment.
Similarities
Despite their differences, CBT and mindfulness-based therapies share some commonalities:
* Focus on Present Experience: Both approaches encourage clients to pay attention to their current thoughts and feelings, although the methods of engagement differ.
* Treatment Goals: Both aim to reduce psychological distress and improve emotional regulation, albeit through different pathways.
* Integration Potential: Mindfulness techniques are often integrated into CBT to enhance its effectiveness, leading to approaches like Mindfulness-Integrated Cognitive Behavioral Therapy (MiCBT).

Question 31

Something about why treatment of pediatric anxiety is bad

Answer 31

??Maybe risks of long term med use, stigmatization of normal developmental processes etc. Maybe that eventually kids grow out of it? Need more of the stem to know properly.

Question 32

Risk factors for ADHD

Answer 32

–family history
–maternal stress during pregnancy
–smoking during pregnancy
–alcohol during pregnancy
–preterm birth
–low birth weight
–exposure to environmental toxins i.e lead
–institutional deprivation in early years
–lower SES
–lower maternal education level
–epilepsy
–male gender

Question 33

Risk factors to develop PTSD

Answer 33

–50% of those with acute stress disorder will go on to develop PTSD
–Pre-trauma RFs:
Childhood emotional problems
Prior mental d/o
Low SES
Low education
Prior trauma exposure
ACEs
Cultural characteristics
Lower IQ
Minority population
Family history
Female gender
Lower age

–Peri-trauma RFs:
Severity of trauma
Perceived threat to life
Injury
Interpersonal violence
Military
Dissociation

–Post-trauma RFs:
Negative appraisal
Inappropriate coping
Acute stress disorder
Subsequent exposure to trauma/life events

Question 34

. Consequences of MJ use

Answer 34

Short-Term Effects
Cannabis use can produce immediate effects that typically last for a few hours:
* Feelings of euphoria and relaxation
* Altered sensory perception and distorted sense of time
* Impaired memory, concentration, and reaction time
* Anxiety or panic in some users
* Increased heart rate and blood pressure
* Bloodshot eyes
These acute effects can impair driving ability and increase the risk of accidents.

Long-Term Health Risks
Regular, long-term cannabis use is associated with several potential health consequences:Respiratory Issues: Smoking cannabis can damage the lungs and lead to chronic bronchitis, coughing, and increased mucus production.Mental Health Effects: Frequent use may increase the risk of:
* Cannabis dependence/addiction
* Anxiety and depression
* Psychosis or schizophrenia in predisposed individuals
Cognitive Impairment: Long-term use, especially when started in adolescence, may negatively impact:
* Memory and concentration
* Learning ability and decision-making skills
* IQ in some cases
Other Potential Risks:
* Testicular cancer (some studies show a possible link)
* Cannabinoid hyperemesis syndrome (severe cyclic nausea and vomiting)
* Pregnancy complications and developmental issues in children exposed prenatally
Effects on Youth
Cannabis use during adolescence and young adulthood poses additional risks:
* Greater likelihood of developing cannabis use disorder
* More pronounced cognitive impairments
* Potential interference with brain development

Question 35

Treatment of MDD. One Med and why. 2 psycho therapies.

Answer 35

Fluoxetine—we have evidence in kids, FDA approval (though no HC approval)
Also have evidence for escitalopram, sertraline, citalopram but evidence is best for fluoxetine.
CBT and IPT

Question 36

Something about depressive symptoms adult vs child

Answer 36

–kids more commonly have somatic complaints, i.e stomach ache, headache
–may have more irritable mood rather than classic melancholic mood
–teens are more likely to have symptoms of atypical depression including hypersomnia and hyperphagia
–aggression may be symptom of depression in kids unlike in adults
–kids may not be able to articulate their mood

Question 37

advise parent about SSRIs and SI

Answer 37

Risk is about 1.5-2 fold higher for SI in under-24 age group; data suggests increase in suicidal ideation but no increase in reported deaths.

Important to treat psychiatric disorder as this is major risk factor for suicide.

Question 38

Meds for mania. Meds for bad depression

Answer 38

Mania first line in C&A:
Lithium
Risperidone
Aripiprazole
Asenapine
Quetiapine

Bipolar Depression in C&A:
Lurasidone—first line (HC approved as monotherapy ages 10-17)
Lithium—second line
Lamotrigine—second line
Olanzapine + Fluoxetine—third line
Quetiapine—third line

Question 39

Risk factors for NSSI-

Answer 39

–presence of mental health disorders
–low health literacy
–ACEs
–bullying
–presence of other risky/problematic behaviours
–female gender
–physical health symptoms
–low self esteem
–poor coping strategies

Question 40

Clonidine uses. Mechanism. Dangerous side effects

Answer 40

1st line for tics, 3rd line for ADHD. Opioid & EtOH withdrawal, ODD, akathisia, neuropathic pain

Alpha 2 adrenergic agonist.

Do NOT discontinue abruptly, risk of rebound HTN. Ensure ability to comply with meds (ie. no missed doses). May also have syncope, bradycardia, hypotension.

Question 41

Neuroanatomical abnormalities in adolescents that makes them more susceptible to using drugs (3 points)

Answer 41

–undeveloped prefrontal cortex
–weak connections between PFC and nucleus accumbens
–reduced inhibitory control over striatum and STN
–Building on the work of others, we suggest individual risk for SUD emerges from an immature PFC combined with hyper-reactivity of reward salience, habit, and stress systems.
–Early puberty onset is associated with earlier initiation and increased frequency of nicotine and alcohol use in adolescent males and females
–Specifically, adolescents exhibit A) poor executive control, resulting from reduced inhibitory control of the orbitofrontal cortex (OFC), dorsolateral PFC (DL), and anterior cingulate cortex (ACC), over more developed subcortical regions such as the striatum (S) and subthalamic nucleus (STN). Adolescents also attribute B) increased incentive salience to reward-related cues, due to elevated excitation in projections between the ventromedial PFC (VM), the ventral striatum (including the nucleus accumbens) and amygdala (A). Finally, adolescents are more prone to C) formation of habitual over goal-directed behaviors. Habit formation in adults involves a progressive recruitment (increased activation) of the VMPFC to the ventral striatum (pathway 1) followed by increased activity in the ACC (pathway 2), to the striatum (pathway 3), and motor cortex (pathway 4). In contrast, adolescents show evidence of direct excitatory projections between the VMPFC and dorsal striatum (S), providing a shortcut to the formation of habits.

Question 42

Personality disorder that can’t be dx until 18 yrs

Answer 42

ASPD

Question 43

Personality disorder that improves over time

Answer 43

–BPD, ASPD

Question 44

Questions about treating tics in context of PANDAS

Answer 44

Behavioral Interventions
Comprehensive Behavioral Intervention for Tics (CBIT) and Habit Reversal Training (HRT) are considered first-line treatments for tics in PANDAS. These techniques help children:
* Become aware of their tics and premonitory urges
* Develop competing responses to suppress tics
* Learn relaxation techniques
* Identify and address situations that worsen tics
CBIT and HRT have been shown to be effective in reducing tic frequency and severity.

Pharmacological Approaches
While medication use should be cautious, some options include:
* Benzodiazepines: May be considered as a first treatment to address anxiety, agitation, and insomnia associated with PANDAS.
* Other psychoactive medications: Can be helpful, but should be started at low doses and titrated slowly due to potential increased sensitivity in PANDAS patients.

Treating Underlying Infection
If a streptococcal infection is identified, appropriate antibiotic treatment should be administered according to established guidelines.
Immunomodulatory Therapies
In cases with persistent or disabling symptoms, immunotherapies may be considered, but only within the context of clinical trials.

Supportive Care
* Cognitive Behavioral Therapy (CBT): Helpful for managing associated behavioral problems.
* Educational Accommodations: May include preferential seating, permission for breaks, extended test time, and additional support for math and executive function.
Cautions
* Tics are not always a primary treatment target unless they cause significant interference or distress.
* The use of psychotropic medications for PANDAS/PANS is common but lacks controlled trial evidence.
* Overdiagnosis of PANDAS may lead to unnecessary treatments.
It’s important to note that treatment should be tailored to each individual child’s needs and symptoms, under the guidance of experienced healthcare professionals. The goal is to manage symptoms effectively while minimizing potential side effects or unnecessary interventions.

For tics generally (not in PANDAS) first line pharmacological is clonidine, guanfacine XR. Then second line is rispridone, abilify. There is strong evidence for Behavioural treatment, clonidine and guanfacine in kids with tics. Fluoxetine is not recommended.

Question 45

How to advise parent to help child when parents have divorced (5 points)

Answer 45

–Family protective factors in divorce:
*Protection from conflict between parents
*Cooperative parenting (except in situations of domestic violence or abuse)
*Healthy relationships between child and parents
*Parents’ psychological well being
*Quality, authoritative parenting
*Household structure and stability
Supportive sibling relationships
Economic stability
Supportive relationships with extended family
–One of the most important ways parents can reassure their children in these times of great uncertainty is to affirm their abiding love for them.

–consider evidence based interventions: Programs such as the Children of Divorce Intervention Program (CODIP) provide group support and skills that help children by reducing their sense of isolation, clarifying misconceptions, and teaching them how to communicate better with their parents, problem solve and develop other important life skills that are particularly important in times of uncertainty and change.19 CODIP has shown multiple benefits to children of various ages and cultural backgrounds in their social and emotional adjustment, school engagement and reduced anxiety and complaints of physical symptoms.20

–three elements:
1. Preparing children for changes by giving them accurate, age-appropriate information helps children to feel secure by addressing that all-important question: “What’s going to happen to me?” Having specific information about what will change and what will remain the same also helps to reduce their worry about parents, their siblings, their pets, their friends and their extended family. As an advisor to the Sesame Street Resilience Project, we developed materials for parents and caregivers to help children understand divorce and family changes. These materials are free and available at sesamestreet.org/divorce.
2. Reducing the number of changes in children’s lives is another important step parents can take to protect them in the aftermath of separation or divorce. It’s easiest for children if they can maintain important relationships, go to the same school and activities, and keep their pets. Maintaining structures and routines that are least disruptive to children is important, too, and often their needs change over time. Parents need to stay attuned to how the transitions between them are impacting their children and make adjustments as needed to prevent giving children the sense that their lives are out of control.
3. Underlying all that parents do to take care of their children is the important – and often difficult – task of taking good care of themselves. Stress often brings on a number of unwelcome changes in sleep, appetite and physical tension. These are generally compounded by additional pressures on the schedule created by sharing the parenting responsibilities from two different homes and the financial impact of splitting the same income to cover additional expenses. Parents need to make it a priority to find healthy ways to manage and reduce stress and take care of themselves so they can parent in the best way possible.

–recognize the impact of family restructuring on your child
–educate yourself (i.e parenting after separation course given by Families Change BC)
–use child friendly resources to explain divorce i.e Sesame Street Explains Divorce
–choose a process that minimizes conflict i.e mediation, collaborative law
–keep your behavior supportive
–Reassuring children that they are loved by both their parents, letting them know the separation is not their fault, and being available to answer your children’s questions are important.
–The three biggest factors that impact children’s well-being during and after their parents’ separation or divorce are potentially within parents’ control: the degree and duration of hostile conflict, the quality of parenting provided over time, and the quality of the parent-child relationship. Underlying these, of course, are parents’ own well-being and ability to function effectively. By learning how to manage their conflict, parent effectively, and nurture warm and loving relationships with their children, parents can have a powerful, positive effect on their children, even as they undergo multiple difficult changes in their own lives.

Question 46

How to advise parent to help child whose parent died in a car accident (5 points)

Answer 46

–From Child Mind Institute:
Follow their lead (i.e answer their questions, but avoid overwhelming them with info)
Encourage children to express their feelings (do not try to shelter/protect child by hiding parents own sadness but try not to let children see you at your most upset moments)
Don’t use euphemisms (i.e passed away, gone)–age appropriate information
Maintain normal routines as much as possible
Memorialize the person who died

–use simple words to talk about death
–listen and comfort–> “being with”
–put feelings into words
–tell your child what to expect
–explain events that will happen
–give your child a role
–give comfort and reassurances
–give your child time to heal from the loss
–get more help if needed
–Explain the death using developmentally appropriate words and make sure children know that they will still be taken care of. In the case of the death of a parent, no matter what the child’s age, professional counseling is often a good idea.

Question 47

Eating disorders and treatment (non-pharm (list 2), pharm (list one), and what not to prescribe)- off new eating disorder guidelines

Answer 47

Non-pharm treatments: Maudsley Family Therapy, CBT-E, nutritional rehab, psychoeducation
(need nutritional rehab first!)
Can also consider IPT

Pharmacological treatments can include olanzapine, SSRIs (but no evidence for efficacy in core AN symptoms). Benzos before meals can reduce anxiety with eating.

Don’t use TCAs, MAOIs, stimulants, buproprion.

Question 48

Cannabis- bad short term effects that are not psychosis

Answer 48

–confusion
–anxiety/fear/panic
–impaired reaction time, memory etc
–decreased BP, tachycardia
–increased risk of MVAs
–impairs learning and memory
–impaired motor coordination

Withdrawal–> irritability, anger, anxiety, insomnia, adbo discomfort

Question 49

ADHD and stimulant- what do you advise to help with appetite and caloric intake (5 points)

Answer 49

–reduce dose
–switch med
–set timers for meals and snacks
–increase caloric value of foods
–more frequent but smaller meals
–bigger meals after stimulant has worn off or before you take the med
–easy to consume meals and snacks

Question 50

Mania - factors what would make you consider lithium, factor that would not make you consider lithium, 2 pharm treatments for mania

Answer 50

Consider lithium if:
–classic euphoric mania
–fewer prior mood episodes
–mania depression euthymia course
–family history of bipolar disorder and/or of good lithium response
–cognitive symptoms present
–suicidality present
–low rates of comorbidity

Maybe don’t consider lithium if:
–kidney dysfunction
–inability to engage with monitoring
–mixed states predominate

Pharmacologic treatments for mania:
Lithium
Risperidone
Aripiprazole
Asenapine
Quetiapine

Question 51

Childhood onset schizophrenia characteristics

Answer 51

negative symptoms and thought disorder are LESS common in youth with psychosis compared to adults

criteria for psychotic disorders tend to be incompletely or atypically presented

in terms of hallucinations in kids with psychosis vs adults: less elaborate hallucinations, somatic and visual are more frequent, less elaborate delusions–> often have adolescent themes, 80% have AH

youth with psychosis compared to adults present in terms of social functioning with failure to meet social and academic outcomes, often for the first time

Delusions:
kids–> usually POORLY elaborated and VAGUE; may build on real experiences i.e being teased

adults–> usually SPECIFIC and COMPLEX

Hallucinations:
kids–> often MULTIMODAL (auditory, visual, tactile); often given names which may be stereotypic i.e the devil

adults–> AUDITORY much more common than any other modality; seldom personalized

Disorganized speech:
kids–> may be hard to distinguish from developmental language disability especially given premorbid disabilities

adults–> clear difference from previous state

Disorganized behaviour:
kids–> similar to adults, but parents may exert more control and minimize effects

Common comorbidities:
kids–> ASD, ADHD, ODD, anxiety disorders, depression

adults–> depression, SUDs, cannabis use assoc with earlier adult onset but rare before middle-teen years, ASD sx before age 3

Course is more SEVERE if childhood onset vs adult onset

incidence of psychotic symptoms in healthy children is high–> tends to diminish after age 6–> can be up to 5%

clozapine tends to be MORE efficacious in childhood onset SCZ compared to adult onset.

Question 52

Risk factors for depression in kid with ASD (3 points), risk factors for SI in kid with ASD (2 points)

Answer 52

Depression RFs:
–alexithymia
–self awareness of deficits
–higher cognitive functioning
–capacity for introspection
–quality of social relationships
–adolescence
–stressful life events

SI:
–ASD combined with exceptional cognitive ability (i.e IQ above 120) is higher risk for SI
–co-morbid anxiety and/or OCD
–perceived loneliness
–presence of externalizing behaviors