volume 1 Flashcards
Which of the following statements is false?
a) children with repaired congenital heart diseases are more likely to have ADHD
b) children with arrythmias have an increased risk of sudden death
c) the risk of sudden death in children with ADHD on medications is much higher than other children in the population
d) autopsies of young patients with sudden death often reveals underlying cardiac abnormalities and family history of sudden death
c) false - same risk as those children in the general population, those who have sudden death likely
Possible under-reporting, a report of increased odds of stimulant use in patients with sudden death compared with motor vehicle deaths, and rare deaths with the initiation of medication remain reasons for continued research in this area
lots higher, it is 58 /100000 patient years
however when patient years of medication are incorporated, much lower risk 0.2-0.5/100000 patient years
statement doesn’t cover non stimulant ADHD meds - i.e. atomoxetine, alpha agonists, anti-depressant
rate of sudden death in Canada not published, other countries it is 1.3-8.5 per 100000patient years
ADHD - affects 3-7% of children
most heart disease not detected before death
risk of death is higher in heart disease than not
a) unclear if association related to perisurgical factors, environmental, genetic, no studies of use of meds for this group of repaired CHD’
sudden death associated with sudden conditions - tetralogy of fallow/transposition, particularly after Mustard and Senning procedures
b) true, Brugada, WPW, arrythmogenic right ventricular cardiomyopathy, long and short QT syndrome, hypertrophic and dilated cardiomyopathy - have increased chance of sudden death, even without stimulant medication; risks of stimulant in this population also unknown
Which of the following findings does not necessitate a cardiac evaluation prior to starting medications?
a) poor exercise tolerance and/or shortness of breath
b) family history of long QT syndrome
c) delayed femoral pulses
d) fainting after prolonged standing with pre syncopal symptoms
d) is the answer, this is less likely to be cardiac, however fainting with exercise or with startle/fright or palpitations with exercise DO necessitate cardiac evaluation
functional mumur does not prevent use of medications
the rest all do necessitate an investigation by paediatric cardiologist prior to starting medications; absence of positive response should not be considered guarantee of safety
other things to ask (based on checklist)
history: palpitations and fainting with exercise/fright, poor exercise tolerance or SOB with no other explanation
Family History of sudden death: include drownings, MVCs without explanation, SIDS
Personal or FHx of non ischemic heart disease: including long QT syndrome, WPW, cardiomyopathy, heart transplant, pulmonary hypertension, implantable defibrillator , MVCs/drowning
Physical exam: organic murmur, hypertension, sternotomy, other abnormal findings
Which of the following statements is false?
a) ECG should be performed prior to starting stimulant medication for ADHD
b) patients with known congenital heart disease or arrythmias can be prescribed ADHD medication by the physician following them for their ADHD, with discussion with their cardiologist as needed
c) any patient with newly identified risk factors for cardiac disease should be seen by a cardiology (regardless of whether they have ADHD)
a) false - no evidence to suggest that this needs to be done when history, family history and P/E are normal, may lead to increased risks of inappropriate treatment being discontinued
the rest are true
b) no further increase known in this population with ADHD meds
cardiologist may suggest further investigation or specific follow up in individual cases; in person investigation by the cardiologist is rarely necessary
c) true - the risk factors are based on the checklist in the statement (see previous question). no evidence to suggest routine cardiology consult prior to beginning ADHD medication
**overall, low grade of recommendations and not the fanciest evidence for these recommendations
Which of the following is not increased in children of divorced parents?
a) lower academic achievement
b) risky sexual behaviour
c) later marriage or cohabitation
d) poverty
c) in fact earlier marriage or cohabitation is associated
also negative effects on psychological and social adjustment/relations
Which of the following is not one of the top 3 significant factor that impact a child’s well being during a parental separation?
a) the quality of parenting
b) amount of counselling received by the children
c) the quality of parent child interaction
d) the amount of hostile conflict
b) is not listed as one of these factors, the other 3 are the 3 most impotent that the statement focuses on
effective parenting - love as well as discipline and limit setting
parent child relationship and comforting etc. (most research focuses on motor-chip)
control conflict - try to have a businesslike relationship between parents ; may need to involve mediation, legal, mental health pros to help
Which of the following interventions has not shown to be helpful for children experiencing parents’ divorce?
a) group support
b) entering a new relationship quickly
c) joint custody
b) entering a new relationship quickly can increase the child’s sense of loss and fear of getting their parent replaced
shown to decrease isolation, anxiety, physical complaints and school engagement children with joint custody do better attachment at 7-9 months peak attachment is from birth to 5 years there is a handout for parents
Which of the following is not true of selective serotonin reuptake inhibitors?
a) some of them commonly lead to withdrawal if abruptly stopped
b) different SSRIs have varying effectiveness and side effects
c) metabolized by the liver
d) absorption is affected by food
d) false - not affected by food, so coadministration with food is a good strategy to help with the GI side effects
fluoxetine, sertraline, citalopram, escitalopram, fluvoxamine and paroxetine.
mechanism
the rest are true
a) generally long acting drugs, given once daily in the AM,
propensity to lead to withdrawal on abrupt cessation generally related to half life of a particular SSRI
mechanism of SSRI - prevent reuptake of serotonin, accumulates in the synapse, some within the broader class also affect other neurotransmitters (dopamine, norepi) therefore can have varying effectiveness and side effects
Which of the following SSRIs has been found to have the highest incidence of withdrawal on abrupt discontinuation?
a) paroxetine
b) fluoxetine
c) sertraline
d) citalopram
a) paroxetine (paxil) associated with most withdrawal on abrupt discontinuation
fluoxetine (prozac) associated with fewest withdrawal symptoms
half life of some SSRIs might be shorter in children than adults, so more likely to cause withdrawal symptoms
Which of the following is not a necessary management plan?
a) consider ruling out other etiologies such as hypothyroidism
b) to assess possible comorbidities such as hepatic impairment when clinically suspected
c) do routine lab work before starting SSRI treatment in all patients
d) consider child and adolescent psychiatry consult when prescribing SSRI in patients with other medical conditions and/or in combination with other medications
c) don’t need to do routine labs, only in the cases mentioned here as well as to monitor other medications that are given concurrently (i.e. valproic acid)
Which of the following SSRIs has the shortest half life?
a) paroxetine (Paxil)
b) sertraline (Zoloft)
c) fluvoxamine (Luvox)
d) citalopram (Celexa)
c) shortest half life 15 hours
the others:
a) paroxetine - 21 hours
b) sertraline - 26 hours
d) citalopram - 35 hours
other SSRIs and their half life include:
fluoxetine (prozac) - 96 hours
escitalopram - 30 hours
Which of the following is the most effective SSRI for adolescent and childhood depression based on research studies?
a) paroxetine
b) fluoxetine
c) sertraline
d) citalopram
b) fluoxetine (Prozac)
SSRIs not approved for children and teens in Canada, need to be very careful to document
for depression in USA: fluoxetine approved for kids in US, escitalopram for adults
RCTs suggest that SSRIs are effective in treating adolescent depression40-70% response rate
also that most effective in children
other ones:
teens - escitalopram some benefit; one study each for citalopram and sertraline (but other studies with negative benefits)
Which of the following was the most effective at treating adolescent depression in the largest study of treatment of adolescent depression?
a) CBT
b) fluoxetine and CBT with fluoxetine
c) placebo
d) fluoxetine only
b) severe and persistent depression, benefitted equally from fluoxetine alone and CBT with fluoxetine compared to the other arms (TADS study)
Which of the following is not a common side effect of SSRIs?
a) sleep disturbances
b) restlessness
c) GI symptoms
d) increased sexual arousal
d) sexual dysfunction is in fact associated
sleep disturbances can include sleeplessness or increased sleepiness, can also have appetite changes
can have behavioural activation - if this happens, should do early investigation of hypomania
Which of the following is not a rare side effect of SSRIs?
a) short QT
b) SIADH
c) increased bleeding
d) serotonin toxicity
a) FALSE - long QT has been associated with citalopram when used in doses of >40 mg, also dose dependent arrythmias occur at these doses; children and adolescents with long QT should not be treated with citalopram
the other side effects have been listed as rare side effects
serotonin syndrome/toxicity involves symptoms of :
- diaphoresis, fever, autonomic symptoms, mental status changes, myoclonus, ataxia
Which of the following conditions is okay to treat a child with citalopram?
a) congenital long QT
b ) dose of 35 mg daily
c) hepatic impairment
d) congenital heart disease
e) propensity to arrythmias from electrolyte disturbances
b) should be okay provided there are no other contraindications;
congenital long QT - contraindication
the other ones should be prescribed with caution
children with any of the relative contradictions should be monitored very closely for arrythmias, including torsades de points
Which of the following statements regarding SSRI use is false?
a) more children will likely benefit from treatment with SSRI than may report suicidality (by about 10x)
b) close initial monitoring as well as documentation of adverse effects is required
c) children should be on a starting dose of SSRI for at least a month before adjustments are made
d) the risks of untreated depression outweigh the risks of SSRI use
c) false - should aim to achieve minimal effective dosage over 1-2 weeks - shouldn’t stay on an ineffective dose for prolonged period with symptomatic distress
the rest are true
When should follow up be arranged following initiation of SSRI treatment?
a) weekly for the first month, then every 2 weeks for the next 4 weeks, then at 12 weeks then as clinically indicated
b) weekly for the first month, then every 2 weeks for the next 8 weeks , then at 12 weeks then as clinically indicated
c) biweekly for the first month, then every 2 weeks for the next 4 weeks, then at 12 weeks then as clinically indicated
d) every 2 weeks for the first 2 months, then monthly until 12 week point, then as clinically indicated
a) is the answer weekly for the first month, then every 2 weeks, then at 12 weeks then as clinically indicated
* *note, once effective dose is reached, then to reassess every 4 weeks to see if dose needs to be adjusted and monitor for side effects
this is what the FDA suggests
the psych people support this, although they do acknowledge the lack of evidence suggesting that face to face meetings reduce suicide risk
phone contact might be appropriate between visits
always check adherence because abrupt adherence (except for fluoxetine) could lead to withdrawal or increased suicide risk
How long should treatment of depression with SSRi be continued prior to weaning the dose?
a) 3-6 months
b) 1-3 months
c) 6-12 weeks
d) 6-12 months
d) 6-12 months to minimize the chance of relapse
should taper the dose
kids with lots of comorbidities or complex psych stuff should see a psychiatrist before med discontinuation (if repeated depression episodes, psychosis, other psych comorbidities)
taper should happen during a relatively stress free time (i.e. summer) and be done gradually
Which of the following is true?
a) citalopram doses should not exceed 40 mg/day in children/adolescents
b) one should not start SSRI if there is substance abuse and depression
c) anxiety is best treated with medical treatment with SSRI
d) benzodiazepines are the best 1st line choice for treatment of anxiety in children/teenagers
a) true - this is the maximum dose
b) false - these comorbidities should not preclude starting an SSRI but it is a complex relationship/decision
c) false - best treated with multimodal approach - psyched, psycho therapy and family interventions
d) false - SSRIs are the best choice
SSRIs can be considered early in the treatment of anxiety if anxiety symptoms are severe or impairing or if the anxiety prevents the child from benefiting from psychotherapy
anxiety symptoms - should screen before starting SSRI so they don’t get attributed to that, also should screen for bipolar (so they don’t “switch” over to bipolar)
Which of the following SSRIs is the best choice for anxiety treatment in children/adolescents?
a) fluvoxamine
b) fluoxetine
c) sertraline
d) none of the above
d) none of the above - in contrast with the studies on depression, there has not been a clear cut favourite for anxiety treatment
Fluoxetine, sertraline and fluvoxamine have all shown some benefit for generalized anxiety disorder
Which of the following SSRIs is the best choice for treatment of social phobia for children/adolescents?
a) paroxetine
b) fluvoxamine
c) fluoxetine
d) none of the above
d) all 3 have been shown to be effective for social phobia
separation anxiety - showed fluvoxamine is the most effective for this in one study,
another study : no advantage of fluoxetine over placebo for this indication
no controlled studies for citalopram or escitalopram
one study also showed that fluoxetine can work for selective mutism
therefore, choice of SSRI should be based more on SSRI that has worked in 1st degree relatives, and tolerability rather than on empirical evidence
see table of studies in the statement
Which of the following is not one of the recommended precautions for using SSRI in anxiety (vs for depression)
a) should include psychoeducation
b) should start at lower doses than for depression
c) no need to monitor for suicidality because no risk of suicide in anxiety
d) gradual titration to therapeutic doses
c) false - although the studies that talk about suicide risk with SSRIs were in depressed patients, prudent to monitor anxious patients on SSRIs also
Which of the following is false of autism treatment?
a) the Lovaas method is the clear gold standard
b) the Lovaas method is the most common early intensive behavioural treatment for autism
c) Lovaas method shown to increase IQ by 30 points in one study
d) Lovaas method shown to increase likelihood of being in a regular classroom in one study
e) results of the above study should be interpreted with caution since the study had numerous deficiencies
a) false no gold standard so far based on current studies
the rest
Lovaas method - tries to build positive behaviours and suppress negative ones, intensive treatment for 2-3 years by child’s caregivers for most waking hours
studies so far:
numerous showed increase in IQ, but not fantastic studies, also showed improvement in PDD-NOS
early treatment leads to better outcomes than older treatment in most studies
normalized training is less structured, the teacher bases the intervention on what the child is doing(more loosely structured) vs the discrete trial of Lovaas where the teacher sets the pace
other programs (not as many studies): LEAP - classroom based, 3 hours daily, practice and behavioural analysis using peers Floor time - home based, 8 or more 20-30 minute sessions per day, parents do the work with therapists, follow the child's play with behavioural goals TEACCH: teaches to functional optimally in society as an adult; only study with controlled study comparison, but flawed study
Which of the following is the estimated prevalence of autism spectrum disorder per 10 000?
a) 10
b) 27.5
c) 15
d) 2.5
b) 27.5
definition of autism: impairment of social relatedness, delayed and disordered communication, and restricted, perseverative and stereotypic behaviour
prevalence of autism spectrum disorder is reported at 27.5/10,000. This is comprised of a prevalence of 10/10,000 for autism, 15/10,000 for pervasive developmental disorder – not otherwise specified (PDD-NOS) and 2.5/10,000 for Asperger syndrome
disorder of brain development, thought to be largely genetic
Overall which of the following statements regarding autism treatment is false?
a) trend towards benefit with intervention
b) no clear benefit
c) should aim for a minimum of 25 hours per week of structured, individualized teaching
d) family should be involved in treatment
e) treatment programs should have a research arm since more well designed trials are definitively needed
c) false - should aim for minimum of 15 hours of structured individualized teaching based on studies to date
The optimal age and IQ range of children, optimal intensity, duration of treatment and parental involvement, as well as the magnitude of effectiveness of these programs, need to be determined. Consensus is required on the outcome measures that will most accurately reflect change in functioning. Direct comparison of the various intensive treatment programs is needed.
Which of the following groups is not an appropriate form of dietary management for ADHD?
a) adjusting diet in children with atopic histories
b) adjusting diet in children with family history of migraine
c) adjusting diet to limit sugar and aspartame intake
d) adjusting diet children with family history of food reactivity
c) false - not evidence to suggest that sugar and aspartame affect children’s behaviour
the other 3 groups can be considered for individualized dietary management in select cases
the other theories include yeast being the cause (not proven)
Which of the following is false of micronutrient deficiencies in ADHD?
a) megavitamin therapy has been shown to be of no benefit in ADHD treatment
b) one study did show benefit of magnesium supplementation although routine supplementation is not justified
c) blinded placebo control studies showed benefit of fatty acid supplementation in ADHD
d) proven iron deficiency, pyridoxine deficiency, zinc deficiency should be treated
e) overall, children with ADHD may need a daily multivitamin to help meet their daily nutrition requirements
c)false - did not show benefit, fatty acid includes evening primrose oil
treat proven micronutrient deficiencies, but no evidence for routine iron supplementation; one study showed benefit to pyridoxine treatment routinely but not enough to justify routine supplement, only give if deficient
the rest of the statements are true
megavitamin therapy includes B6, niacin amide, ascorbic acid, pantheotecane; also concerns about toxicity of this
one study showed that healthy ADHD babies have lower zinc levels than others, but still no evidence to supplement beyond the recommended daily levels of zinc; evening primrose oil apparently works by improving zinc
Which of the following may have a specific role in improving ADHD?
a) piracetam
b) ginko biloba
c) St John’s wort
d) algae
b) gingko biloba - because of effects on memory and cognition in adults, has been used for ADHD in children
no systematic studies in ADHD
S/Es: headaches, dizziness, palpitations, GI upset, allergic skin reactions; don’t use with anticoagulants or anti platelet (i.e. ASA) or with bleeding disorders
a) piracetam - nootropic, helps with neuro chemistry but not specific to ADHD
c) St John’ s wort: no clincal trials in use in ADHD, is used as an antidepressant, recent evidence that interacts with cytochronme P450 drugs (i.e. theophylline, warfarin, cyclosporine, indinavir, OCP)
Which of the following drugs and side effects are incorrectly paired?
a) lemon balm- contraindicated in Graves disease
b) herbal teas - may diminish iron absorption and lead to atopic dermatitis and allergies in children with hay fever
c) passion flower - hypersensitivity vasculitis and altered consciousness
d) hops - nausea, diarrhea, numbness and tingling
d) false, side effect of hops (for anxiety disorder ) leads to allergy and disruption of menses
herbal teas - to help with sleep
valerian and lemon balm- help with sleep,
valerian - safe , SE GI upset and headache
Which of the following herbal medication had a stop sale order by Health Canada?
a) passion tower
b) St. John’s wort
c) kava
d) valerian
c) kava - repots that has anti anxiety properties without affecting cognitive function, series side effects include scaly rash, liver dysfunction, muscle weakness, coordination problems
Which of the following treatments may be helpful to treat ADHD?
a) hypnotherapy for associated symptoms
b) visual stimulation
c) sound training
d) oculovestibular treatment
a) hypnotherapy for associated symptoms hypnotherapy - no study in improving core symptoms, but has shown some benefit to improving associated symptoms (tics, sleep disturbances)
However, neurofeedback offers an alternative for patients who present significant side effects with stimulant medication, show a poor treatment response or refuse to consider medication
**whole long list of drugs and specific side effects, look at it again.
True or false - the prevalence of post partum depression in Canada is less than the overall prevalence of depression
false - rate of post partum is higher (13%) vs 6% for depression( females 2x more likely)
maternal depression is a risk factor for child development
