Week 11 Developmental Disabilities and Pediatric/Adolescent Mental Health

Question 1

adolescent depression is higher:

Answer 1

• females
  
  • by age 14, it is 2x in girl
• having depressed parents have 3x the risk
  
  • peak 15-20 yrs

Question 2

what framework gathers info about young person’s life and aids in gathering history:

Answer 2

• HEADSS
  
  • Home
  • Education, employment, eating, exercise
  • Activities and peer relationships, social media
  • Drug use, prescribed meds, cigarettes, vaping, alcohol and other drugs
  • Sexuality and gender
  • suicide, self harm, safety, and spirituality

Question 3

when to start MDD screening in adolescents? what tools?

Answer 3

• ALL adolescents beginning age 12-18
• pediatric symptoms checklist (PSC) - 4 yrs to 18 yrs
• Beck Depression inventory - adolescents
• PHQ-2 (if > 3, do PHQ-9) - 6 yrs and up
• CDRS-R

Question 4

depression in adolescents vs adult

Answer 4

• adolescents: don’t admit to “feeling sad” but have mood swings, irritability, short tempered, temper tantrum, social w/drawal, somatic complaints
• toddlers: lack energy, too eager to please others, clingy

Question 5

depression diagnosis criteria

Answer 5

• _>_5 symptoms below AND depressed mood or anhedonia x 2 weeks:
• SIGECAPS:
  
  • Sleep changes/insomnia
  • Interest (loss) - anhedonia, hopelessness
  • guilt, worthlessness
  • energy loss, fatigue
  • concentration/cognition (decreased)
    
    • school/hw
  • appetite (changes)
    
    • increase/weight gain
  • psychomotor (agitation/retardation)
  • suicide

Question 6

Management for adolescents with depression

Answer 6

• Cognitive behavioral therapy
• mild: CBT. if no response in 6-8 weeks, meds!
• complex: CBT + SSRI (1st line) [or SNRI/citalopram]
  
  • fluoxetine (Prozac) for > 8 yrs
  • escitalopram (Lexapro) > 12 yrs citalopram (Celexa) and sertraline (Zoloft)
  • always CBT with meds (never alone)
• always assess suicide risk
• r/o underlying causes (CBC, TSH, CMP, B12, Folate)

Question 7

avoid what medication as treatment for adolescent depression?

Answer 7

• paroxetine (Paxil)
  
  • a/s with increased suicide ideation
• TCA’s (-tyline/nortripyline) = no benefit either

Question 8

follow up interval for SSRI in adolescent

Answer 8

• EVERY week x 4 weeks, then every other for at least 2 visits
• again 12 wks later
• Once remission of sx’s, f/u every 3 months
  
  • continue meds for 6-12 months after remission WITH CBT
• always screen for SI/recurrent depression & document
• if stop meds, taper slowly over 1-2 months

Question 9

why follow up so quickly for adolescents on SSRI’s?

Answer 9

• slight increase in suicidal ideation when starting SSRI educate to look out for it

Question 10

if SSRI not helping adolescent depression and you maxed out the dose…

Answer 10

• switch to another SSRI!
• if 2nd SSRI no work → refer to psychiatrist (they will switch to another class, venlafaxine or bupropion)

Question 11

General screening q’s for youths about nutrition and body dissatisfaction

ask this T/F question for diabetic youths

Answer 11

• how do you feel about your weight?
• how much do you like to weigh?
• do you, ur friends, or ur fam have any concerns about your eating, exercise, or weight?
• “I sometimes take LESS INSULIN than I should”

Question 12

purging behavior (bulimia) can lead to

Answer 12

• loss of gastric acid
• hypokalemic hypochloremic
• metabolic alkalosis
• laxative abuse → hypokalemia

Question 13

DSM 5 diagnosis of ADHD

Answer 13

• < 17 yrs old:
  
  • need 6 or more hyperactivity/impulsivity sx’s
  • OR 6 or more of inattention sx’s
• > 17 yrs old, need 5 or more
• sx must:
  
  • occur often, in 2 or more settings for at least > 6 months
  • present before 12 months, impair work, school, home, severe
• inattention sx’s:
  
  • fails to pay attention/careless mistakes
  • difficulty paying attention
  • doesn’t listen
  • avoids tasks that require sustained mental effort
  • loses things to complete tasks
  • easily distracted
  • often forgetful in daily activities
• hyperactivity/impulsivity sx’s:
  
  • fidgets /squirms
  • leaves seat when needed to be seated
  • runs/climbs when inappropriate
  • trouble playing quietly
  • always on “go”
  • talks excessively
  • answers q’s before q is completed
  • difficulty waiting for his or her turn
  • interrups/intrudes others

Question 14

ADHD scales/screening

Answer 14

• Vanderbilt ADHD
• ADHD rating scale IV
• Connor Parent & Teacher rating scale
• Child attention profile
• CDC checklist

Question 15

types of ADHD

Answer 15

• primary inattentive (6 or more positive behaviors in inattentiveness category)
• primary hyperactive/impulsive (^)
• combined type (6 or more positive in each category)

ADD term no longer used

Question 16

ADHD treatment plan

Answer 16

• identify comorbid conditions & treat
  
  • hearing/vision screening
  • tutoring
• behavior management plan
  
  • identify specific goals (2-3 behaviors)
  • reward system for meeting goals
  • online resources AAP, CDC< CHADD
• medication - stimulants + CBT
  
  • NO meds for preschoolers unless severe/refractory to CBT

Question 17

challenges in diagnosing and treating ADHD in adults

Answer 17

• comorbidities (anxiety, depression, drug use)
  
  • refer mental health
• childhood symptom recall (sx’ before age 7?)
  
  • mostly primary inattentive bc not disruptive
• behavior scales
  
  • ASRS scale with 18 behaviors, need to be in 2 settings
  • tx difficult bc CVD, abuse,

Question 18

meds for ADHD

Answer 18

SNRI - Atomoxetine (Strattera) non stimulant

methylphenidate

Question 19

Down syndrome features

Answer 19

• most common: hypotonia (poor muscle tone) & short stature
• microcephaly
• flattened midface
• brachycephaly (flattened occiput), round face
• up slanting palpebral fissures “almond eyes”
• epicentral folds (vertical folds of skin b/t medial acanthi and bridge)
• brush field spots
• protruding tongue
• macroglossia
• short neck, skin folds
• broad shortened hands
• clinodactyly of little finger
• transverse palmar crease
• sandal toe deformity (inc spacing b/t 1st and 2nd toe)

Question 20

Causes and variations of Down syndrome

Answer 20

• nondisjunction of 21st chromosome [most common]
• translocation
• mosaicism
• increasing in rates and affects all racial/socio levels

Question 21

Down syndrome evaluation before discharge

Answer 21

• ECHO! (50% have congenital heart defects) even with no murmur
• TSH
• hearing screening
• CBC (hem abnormalities, myeloproliferative disorder, leukemia reaction, polycythemia)

Question 22

Down syndrome screening

Answer 22

• ECHO
• CBC

screen for:

• congenital heart disease
• childhood leukemia
• thyroid disease (hypo/hyper)
• autoimmune dz (celiac, diabetes, dermatological)
• seizure disorders
• decrease hearing/vision
• autism; behavior problems
• Atlantoaxial subluxation
• sleep apnea (eval by age 4)
• other:
  
  • otitis media
  • bronchitis
  • GI illnesses

Question 23

what tendencies do Down syndrome have that’s normal?

Answer 23

• the “Groove” / OCD tendencies
• self talk / imaginary friends (esp when stressed)

Question 24

neuropsychiatric disorders in down syndrome and what to exclude?

Answer 24

• depression
• Alzheimer disease (1 gene of Alz on 21st chromosome)
• anxiety disorders
• compulsive disorders
• autism
• ADHD
• exclude treatable medical conditions:
  
  • obstructive sleep apnea
  • hypothyroidism
  • celiac sprue
  • atlantoaxial subluxation → behavioral changes

Question 25

screenings for adults with down syndrome

Answer 25

Screen TSH annually/yearly!

• testicular, ovarian, cervical, breast (routine), colon, leukemia (but would have found as child)
• celiac screen in children, not adults
• echo if haven’t already
• ophthalmologic and hearing q 2 years
• sleep study for OSA using polysomnography by age 4 (not routine)
• karyotype is used for diagnosis

Question 26

PE of Down syndrome that warrant special attention

Answer 26

• obesity
• HEENT: cerumen impact, hearing impairment, chronic sinusitis, allergies, reflux, cataracts, keratoconus, vision impair, airway compromise
• thyromegaly, thyroid nodules, atlantoaxial subluxation
• pneumonia
• murmur, cardiomegaly, cyanosis
• testicular masses, cryptochordism, Pap screen
• arthritic changes, hallux valgus (bony deformity on 1st MTP)
• cervical cord compression, nerve root compression, vertebrobasilar insufficiency, motor weakness, ankle conus

Question 27

dysthymic disorder criteria

Answer 27

• category of depression
• depressed mood for most days for at least 2 years
• must not have gone more than 2 months w/o 2 or more of:
  
  • poor appetite or over eating
  • insomnia
  • low energy
  • low self esteem
  • poor concentration
  • difficulty making decisions
  • feelings of hopelessness

Question 28

most important risk factor for suicide

Answer 28

previous attempt!

Question 29

warning signs of adolescent suicide

Answer 29

• obsession/poems essay on death
• dramatic change in appearance
• threats
• guilt/shame/reflection
• making amends
• changes in eating/sleeping
• giving away personal items
• drop in grades

Question 30

hospitalize adolescent for SI if

Answer 30

• plans to access lethal means
• hx of prior attempts
• impaired judgment
• question of safety at home

Question 31

management on generalized anxiety

Answer 31

• excessive anxiety/worry NOT focused on specific person/situation/stressor
• toddler/preschool: CBT and play therapy
• older child: ped mental health therapy + CBT
  
  • consider SSRI
  • NO BENZOs

Question 32

first line treatment for mild to moderate OCD in adolescents

Answer 32

CBT

if severe: SSRI

Question 33

what psych disorder has the highest risk of suicide?

Answer 33

bipolar disorder

90% recurrent after 1st manic. episode

Question 34

bipolar disorder treatment

Answer 34

• SAFETY!
• refer to child behaviors health provider
• lithium (mood stabilizers) alone or with anti seizure meds (valproate, divaproex) or with antipsychotics (risperidone)
• non pharm:
  
  • healthy diet
  • stress reduction
  • routine exercise
  • good sleep hygiene

Question 35

what meds can worsen manic response and cause metabolic disorders?

Answer 35

antidepressants can potential manic

Question 36

what is the most common mental health problem in childhood?

Answer 36

ADHD

more in males

Question 37

ADHD med management (stimulant vs non stimulant)

Answer 37

• stimulant:
  
  • low dose amphetamine (Adderall)
  • methylphenidate: Concerta, Ritalin
  • Amphetamines: adderall, Vyvanse
    
    • more potent than methylphenidate
• non stimulant:
  
  • atomoxetine (Strattera) SNRI for > 6 yrs old
    
    • increase SI risk
  • guanifacine + clonidine > 6 yrs old
    
    • takes 1-2 wks for effect

Question 38

autism stats/patho

Answer 38

5x more common in boys, all racial groups

• MUST have sx at young age and can’t be late onset
• fragile X most common cause

Question 39

autism screening gold standard

Answer 39

• 18 and 24 months during wellness checks
• EARLY INTERVENTION!
  
  • prognosis better if diagnosed < 5 years
• Autism Diagnostic Observation Schedule (ADOS-2) and Autism Diagnostic Interview (ADI-R) gold standard
  
  • M-CHAT screen at 16-30 (toddler) quick, easy
• screen autistic sibling
  
  • if + = refer
    
    • if < 3 yrs: refer for early intervention
    • if > 3 yrs: refer for special education
  • if - & parents concerned, rescreen next visit
• citalopram contraindicated

Question 40

autism behaviors to look for/red flags for early dx

Answer 40

• lack of social smile and eye contact by 2-3 months
• lack of joint attention 9 months
• doesn’t point at objects to show interest by 14 mo
• no babbling/cooing by 12 mo
  
  • doesn’t say a single word by 16 mo
• no pretend by 18 mo
• loss of language/social skills by 2 yrs
• does not respond to name by 1 yr
• gets upset by minor changes
• avoids eye contact / wants to be alone
• repeats words/phrases
• monotone
• flaps hands, rocks body, spins circles
• self injury behaviors (head banging, biting, pinching)

Question 41

autism diagnosis criteria

Answer 41

• deficits in ALL 3:
  
  • social-emotional reciprocity: reduced sharing of interest
  • nonverbal communicative - poor eye contact
  • developing, maintaining and understanding relationships
• 2 or more of:
  
  • repetitive movements, use of objects, speech (echolalia)
  • insistence on sameness, routines, ritualized patterns
  • highly restrictive interest
  • hyper or hyperactivity to sensory or input
• must impair function, present in early development

Question 42

anorexia / bulimia questionnaire

Answer 42

SCOFF

• do you make yourself Sick bc u feel uncomfortably full?
• control - do you worry u lost control over what you eat?
• loss more than One stone in 3 months period
• do you think you’re fat when ppl think you’re thin?
• would u say food dominates your life?

Question 43

anorexia diagnostics

Answer 43

• R/o pregnancy → get UA
  
  • bone density studies with amenorrhea (osteopenia)
• CBC (anemia), electrolytes, fasting glucose (new onset diabetes), thyroid studies (hyperthyroid), LFTs, FSH, LH
  
  • hypokalemia, hypochloremia (purging)
• EKG (PVC’s and QT elongations)

Question 44

anorexia management

Answer 44

• refer behaviors health + dietician + rehab + therapy
• meds that decreases binging/purging:
  
  • antidepressants
    
    • fluoxetine (PRozac) -
    • TCAs [NO in SI pts]
  • atypical antipsychotics
    
    • topiramate (Topamax)
    • olanzapine (Zyprexa) - stimulate appetite/weight gain instead of decreasing binging
• Expected weight gain 1.1 lb per week from referring
  
  • monitor for refeeding syndrome: confusion, irritability, organ dysfunction, seizure)

Question 45

how is Fragile X inherited

Answer 45

• X linked dominant inheritance (FMR1 gene mutation)
  
  • females have XX
    
    • milder sx’s bc have 2 X’s to compensate
  • males have XY
    
    • more sx’s
• 2nd common after Down syndrome
• women: 50% passing chance (carrier or syndromic)
• carrier men:
  
  • pass premutation to ALL daughters (carriers only), none to sons

Question 46

fragile X screening in who?

Answer 46

• pts with autism
• children with intellectual disability (idiopathic)
• children with family hx of

Question 47

Fragile X clinical findings

Answer 47

• (think elephant)
• prominent forehead & jaw
• long ears
• long narrow face
• epicanthal folds
• high arched palate
• increased head circumference
• large testes (macroorchidism)
• club foot/ples planus, hip dislocation, scoliosis
• OSA
• follow age appropriate health promo per AAP Bright futures

Question 48

Turner syndrome

Answer 48

• ONLY females
• Missing X / altered chromosome from error in division
• UNLIKELY TO BE INHERITED

Question 49

Turner syndrome sx’s

Answer 49

• most common: short stature
• loss of ovarian function/immature ovaries/infertility
• no puberty
• heart defects
• webbing of neck (NB)
• lymphedema of hands/feet
• MOST INFERTILE
• normal IQ

Question 50

turner syndrome management

Answer 50

• refer to endocrinology for tx → start Growth Hormone before 4 yrs old for puberty to hit 12-14 yrs
• low dose estrogen first then add progesterone 1-2 years after

Question 51

Klinefelter syndrome

Answer 51

• extra X chromosome (XXY) → getting more feminine features
• MALES ONLY
• NOT an inherited disorder; it’s an error in cell division

Question 52

klinefelter syndrome sx’s

Answer 52

• tall with long arms
• reduced facial/body hair
• gynecomastia/boobies
• small testes
• less facial hair
• narrow shoulders, wider hips
• osteoporosis/weak bones
• infertility
• metabolic syndrome
• cryptocordism / undescended tests
• normal IQ but language/learning problem

Question 53

klinefelter syndrome screening

Answer 53

• if infancy had hypotonia, delayed milestones, screen!
• or all, abdominal fat, clumsy, slow dev skills from 1-5 yrs old

Question 54

klinefelter syndrome management

Answer 54

• testosterone RT at puberty age
  
  • stimulates deeper voice, hair, muscle, libido
• improves bone density
  
  • DOES NOT IMPROVE FERTILITY
  • most men unable to father a child without help of fertility specialist
• fertility treatment: intracytoplasmic sperm injection right into egg
• monitor scoliosis
• annual thyroid screen
• increased risk of autoimmune and malignancies (breast cancer)

Question 55

Marfan’s syndrome features

Answer 55

• cardiac - monitor ~
  
  • aortic root dilation
  • Mitral valve prolapse, regurgitation
• tall, long limbs
• pectus deformities (pigeon)
• joint hyperextensibilities
• eyes: ectopic lentis, myopia, retinal detachment, esotropia/strabismus
• spontaneous pneumothorax
• normal IQ

Question 56

marfans syndrome management

Answer 56

• avoid contact sports
• annual eye exam
• monitor cardiac

Question 57

watch out for evidence of what in patients with anxiety?

Answer 57

physical trauma

Question 58

separation anxiety disorder

Answer 58

• 5-16 yrs old
• most common pediatric anxiety disorder
• meds are NOT helpful
• manage with psycho/education

Question 59

generalized anxiety disorder management in preschoolers

Answer 59

**preschoolers benefit from play therapy

Question 60

peds depression diagnostics/labs

Answer 60

• CBC
• EBV titers
• Vit D
• TSH
• HCG
• UA
• drug screening with NEW onset of depression

Question 61

what can occur 4-6 weeks after a stressful infection?

Answer 61

• PANDAS - pediatric autoimmune neuropsychiatric disorder associated with streptococcus infection
• in peds with OCD and Tourettes
• give PO corticosteroids or IVIG

Question 62

bipolar diagnostics/labs

Answer 62

• urine/saliva/serum sample for toxicology screening if no known previous diagnosis
• CBC
• CMP
• TSH
• renal profile

Question 63

before giving a stimulant for ADHD…

Answer 63

screen for cardiovascular risk (family history, obese, DM, dyslipidemia, hx of stroke/MI/TIA)

Question 64

Prader Willi Syndrome treatment

Answer 64

• loss of function on chromosome 15 → constantly hungry (hyperphagia) at 12-24 months
• hypogonadism → infertile
• give sex hormone, growth hormone

Question 65

Beckwith Wiedemann Syndrome

Answer 65

• overgrowth syndrome affecting infants
• macrosomia
• parts of body growth big and uneven
• omphalocele
• macroglossia
• risk for wills tumor, hypoglycemia

Question 66

what is the expected weight gain per week after refeeding of anorexia?

Answer 66

1.1 lb (0.5kg) per week

monitor for refeeding syndrome (confusion, irritability, organ dysfunction, seizure) from severe fluid and e- imbalance

Question 67

bulimia treatment

Answer 67

• my role: screening & early identification
• referral for children/adolescents bc of sociopyschological dynamics
• nutritional rehab
• cognitive behavioral psychotherapy
• antidepressant (SSRI)
• PE: parotid glands, mouth, dental caries, esophageal or gastric injury, dehydration (from laxatives), ipecac a/s hypotension, tachycardia, arrhythmias
• check e-, Mg, amylase levels

Question 68

diagnostics for eating disorders

Answer 68

• CBC (anemia)
• e- (K, Na, acid-base imbalance)
• fasting glucose (diabetes)
• TSH (hyperthyroidism)
• LFT
• FSH
• LH
• ECG (premature ventricular contractions and QT elongation)
• bone density

Question 69

which medications cause metabolic disorders (Diabetes, dyslipidemia)

Answer 69

atypical antipsychotics