Child & Adolescent Psychiatry Flashcards

Question

What is the indication for using clozapine? List three major side effects unique to clozapine.

Answer 1

**Indication:** treatment resistant schizophrenia (2 adequate trials of antipsychotics, 6-8 weeks duration) Faster if self-injurious, suicidal behaviours, fast response needed **Side effects:** *agranulocytosis (low neutrophils), myocarditis/ cardiomyopathy, seizures, ileus/constipation*, orthostatic changes in BP and HR/ bradycardia hypotension, QTc prolongation, NMS, anticholinergic toxicity, ileus/constipation

Answer 2

· CBC · weekly x 6 months · bi-weekly x 6 months · q4weeks x thereafter

Answer 3

Waist circumference BMI BP HBA1C/ fasting glucose fasting lipid profile Black and indigenous peoples \*\* not evidence-based, stupid

Answer 4

a) Galactorrhea, gynecomastia, decreased libido, sexual dysfunction, decreased bone mass In women specifically amenorrhea, oligomenorrhea, infertility \* b) aripiprazole, quetiapine, clozapine

Answer 5

* Severe emotional stress (grief/loss, recent immigration/ transition) * Depression, in mood-congruent AH * delusions * disorganization * functional change * delusions * mood incongruence * Social withdrawal * Language changes AACAP “Hearing Voices and Seeing Things” 2017

Answer 6

HC – Aripiprazole (15+), JAMP Lurasidone is indicated for the management of the manifestations of schizophrenia in adolescents (15+) FDA – Aripiprazole, Olanzapine, Paliperidone, Quetiapine, Risperidone , asenapine, brexpiprazole, lurasidone

Answer 7

* Antipsychotics are primary treatment * Ongoing medication therapy should be provided to youth with schz * Adjunctive meds to treat associated symptoms (agitation, depression, outbursts) * **Psychotherapeutic interventions should be provided in combination with medication therapies** (cognitive-behavioral therapies, social skills training, cognitive remediation, and family interventions - FT, MI, CBT) * Sudden onset + good pre-morbid function + good response to treatment + good insight + short duration of psychosis * Poor long-term outcome is predicted by low premorbid functioning, insidious onset, higher rates of negative symptoms, childhood onset, and low intellectual functioning

Answer 8

ECT and benzodiazepines Alternative - carbamazepine topiramate valproate zolpidem memantine and bromocriptine

Answer 9

* Functional decline - 30% GAF in past year * Sleep changes * Social withdrawal * Irritability/ anger * Anhedonia, lack of motivation * Negative symptoms – anhedonia, lack of motivation * 3 different UHR groups: Genetic Risk & Deterioration (GRD), (Attenuated positive symptom syndrome) APSS, (brief Intermittent psychotic symptom syndrome) BIPS Social withdrawal and isolation, idiosyncratic or bizarre preoccupations, unusual behaviors, academic failure, deteriorating self-care skills, and/or dysphoria. These changes may be associated with depression, anxiety, aggressive behaviors, or other conduct problems, including substance abuse, which often confuse the diagnostic picture. The prodromal phase may vary from an acute marked change in behavior to a chronic insidious deterioration.

Answer 10

* NSSIB = not suicide attempt but maladaptive coping strategy * Inpatient admission is not helpful and may actually result in further regression of distress tolerance/ emotional regulation skills. * This learning is done in the community.

Answer 11

* Minimize alcohol/ substance use * Skills * Emotional regulation skills * Improve communication * Distraction * Interpersonal effectiveness * Problem-solving skills * Conflict management Skills * Affective Language Skills * Psychotherapies * DBT * CBT (Individual, Family, Parent Training) * FBT-Attachment for SI * IPT – Individual for SI * Psychodynamic therapy-Individual + Family * Safety Planning * Parent Skills Training * Keep environment safe Also Acceptable Answers: * Interpersonal relationships/ supports * Try to remove reinforcements/social contingencies * Recognize warning signs * Develop coping strategies (ex TIPP) * Use friends, family and MH professionals for support * Keep environment safe * Motivational interventions/brief intervention * Use mobile safety planning apps * Mentalization-based treatment? * Affective language skills * Self-soothing skills * Psycho-education for patient and family * Cognitive problem-solving skills

Answer 12

1. Where there any co-ingestions/ concurrent substance use? 2. Was this a suicide attempt? (Clarify SI/ intent/ plan/ access to means (including guns)) 3. History of previous SA 1. Precipitants - stressors, triggers 2. Protective factors – supports, plans, evidence of future orientation 3. Do you live alone? 4. Are you still thinking of suicide? (Screen for depression, mania, hypomania, severe anxiety)

Answer 13

**a) SI, plan, intent, access to means, future orientation** **b) Triggers/ precipitants/protective factors** **c) History of previous SA** **d) Collateral history** **e) Psychiatric diagnoses/comorbidities** f) Protective/ resiliency factors (ex: family, pets, religion) g) Supports (ex : formal and informal) h) Collateral information i) Family history (of suicidality and mood d/o) j) History of abuse, violence, bullying k) Substance use l) Exposure to suicide (ex. in media or friends/school) m) Emotional/cognitive factors: hopelessness, helplessness, impaired problem-solving, agitation, despair, low SE, impulsivity n) Familial conflict o) If part of minority (first nation, lgbtq, …)

Answer 14

**a) Distress tolerance skills** **b) Emotional regulation skills** **c) Distraction** d) Mindfulness, relaxation strategies e) Anger management f) Problem solving approach g) Supports h) Interpersonal effectiveness, friendships **i) Remove “means” – sharps, lighters, etc…**

Answer 15

* Is this patient medically stable? ABC – vitals, LOC, QTc + involve other specialties as needed * Assess Safety (+ Patient status in hospital – voluntary vs. involuntary) * Assess for possible admission

Answer 16

- distraction (holding ice, cold shower) - distress tolerance (TIPP= temperature, intense exercise, pace breathing, progressive muscle relaxation) - emotion regulation techniques - removing sharps and lethal means, and safety proofing home - treat comorbidities - meditation - mindfulness

Answer 17

* AD not approved by Health Canada for those \<18yo; although accepted in other countries (ie: USA). Treatment with AD is guided by Canadian and international treatment guidelines, such as CANMAT, Katzman, Canadian Pediatric Society and AACAP guidelines. * There is a black box warning for increase in SI (not attempts). Note that untreated depression increases risk of SI and attempts. * The FDA warning was based on an analysis published more than one decade ago about industry-sponsored randomized controlled trials (RCTs). However, since then, an increasing number of studies have questioned the methodological rigor of the FDA analysis * Antidepressants very well studied in adolescents

Answer 18

TADS – Treatment Of Adolescents With Depression (2007) * **TADS Key finding: Combination treatment (Fluoxetine + CBT) had the highest response rate** * **Fluoxetine monotherapy better than CBT monotherapy** TORDIA – Treatment Of Resistant Depression In Adolescents 2010 * **Adding CBT to either a new SSRI or an SNRI is superior to just switching meds alone** * **No difference if SSRI vs. SNRI (but SNRI = less tolerability)** CAMS – child & adolescent anxiety multimodal study [separation/ social/ GAD] * **At 12 weeks, combo \> (sertraline= CBT )\> placebo** POTS – pediatric OCD treatment study * **At 12 weeks, combo \> CBT \> Sertraline \> placebo**

Answer 19

In general, the primary pharmacologic effect of amphetamine and methylphenidate = **increase central dopamine and norepinephrine activity**, which impacts executive and attentional function. Methylphenidate – 1. **Blocks reuptake of DA and NE (amp too)** 2. **Metabolized by esterases in the liver (highly variable) – not CYP** Amphetamine – 1. **Inhibits VMAT-2 (which *releases DA form* vesicular storage)** 2. **Inhibits MAO activity --\>** **decreased breakdown of DA/NE** 3. **Eliminated most via kidneys; excreted in urine mostly unchanged**

Answer 20

* Fluoxetine inhibits 2D6 and therefore increases the serum concentration of Strattera. So beware of increasing the dose of Strattera. * Other strong 2D6 inhibitors = bupropion, paroxetine; moderate = duloxetine * Other 2D6 substrates = abilify, venlafaxine, risperidone, olanzapine * Also: watch QTc as both SSRI and Strattera can increase QTc

Answer 21

CADDRA - Switching from a psychostimulant to atomoxetine or guanfacine XR: * Since non-stimulants will take time to show clinical response, it is important to decide if the psychostimulant needs to be stopped before or if you combine both as you start atomoxetine or guanfacine XR. * If the first medication shows no clinical effect despite optimal dosing, stop it and start the non-stimulant as monotherapy, following usual titration strategies. * Only if it is not possible to stop the first medication (and if the first medication shows important clinical effect and needs to be continued until the non-stimulant shows its effects) then keep the first medication and add atomoxetine slowly, following usual titration strategies. * If side effects occur, decide between reducing the psychostimulant versus atomoxetine or guanfacine XR dosage. * Strattera – 0.5mg/kg/day x 7-14 days, then 0.8mg/kg/day x 7-14 days, then 1.2mg/kg/day x7-14 days. Max = 1.4mg/kg/day or 60mg (kids) or 100mg (youth) * Guanfacine – Start at 1mg daily, maintain dose for 7 days, increase by no more than 1mg weekly Max = 4mg in age 6-12, 7mg in 13-17. As adjunct, max = 4mg.

Answer 22

(a) Flumazenil. But more generally, approach to management * ABCs * Naloxone if altered mental status and worried about opioid co-ingestion * IV access, CCM * If respiratory depression, definitive airway management * Usually no decontamination * Flumazenil indicated IF young children with isolated BZD ingestion with severe CNS depression – not in anyone who uses BZD chronically (b) Bind to the GABA-A receptor of neurons; allosteric reaction --\> increased activity of GABA at GABA receptor. Increase influx of Cl, which results in hyperpolarization of the inhibitory neuron --\> less likely it will fire an action potential.

Answer 23

* _Partial_ D2 and 5HT1A agonist * BENEFITS – * Better metabolic profile * Less hyperPL * Slightly less weight gain then other AP * There is an LAI (IM) formulation (Maintena) * DRAWBACKS – * Akathisia * EPS/Parkinsonism * Long half-life making reaching the steady state longer

Answer 24

Practices: * Start low, go slow * Close monitoring of SE * FHx of response * Avoid polypharmacy * Regularly reassess need for the medication and dc unnecessary agents Summary: * Caucasians, Blacks, Asians – slow metabolizer 2D6 * Blacks and Asians – slow metabolizer 2C19 * East Asians – slow metabolizer 3A4 * Differences in glycoproteins – drug transporter * Polymorphisms of 5HT 2A and D3 receptors – more side effects, including EPS, respond to very low doses * Indigenous and blacks: more risks Db2

Answer 25

* Aripiprazole * Quetiapine * Clozapine * Brexpiprazole

Answer 26

1. Risperidone is a substrate for 2D6. Fluoxetine is an inhibitor of 2D6. Therefore, there are increased serum levels of Risperidone = increased SE She could also be a slow metabolizer. Younger patients + certain cultural groups (black) are more susceptible to EPS. Synergism of SSRI + AP that both cause akathisia. 1. Consider a cultural formulation: * **Understanding/ meaning of symptoms/ dx/ treatment – pharmacotherapy** * **Culturally appropriate supports/ care** * **Psychosocial stressors and cultural factors impacting vulnerability/ resilience** * Expression of distress/ idioms of distress * Religious and spiritual beliefs/ implications * Patient-physician relationship and understanding/ trust * Cultural identity * Cultural community implications

Answer 27

* **Agitation/ irritability** * **Excessive Movements/Excitability** * Impulsivity * Talkativeness * Insomnia

Answer 28

* Medication interaction * Inhibition of CYP450 2D6 metabolism by fluoxetine and its active metabolite. * Fluoxetine increases the serum levels of Risperidone * EPS, sedation, dizziness

Answer 29

Medications – steroids, opiate analgesics, anticholinergics

Answer 30

* methylphenidate= Methylphenidate (MPH) non-competitively blocks the reuptake of dopamine and noradrenaline into the terminal by blocking dopamine transporter (DAT) and noradrenaline transporter (NAT), increasing levels of dopamine and noradrenaline in the synaptic cleft. * atomoxetine= SNRI; thought to be related to selective inhibition of the pre-synaptic norepinephrine transporter

Answer 31

[a] From a pharmacological perspective, aripiprazole is different to other antipsychotic agents , as it is the only approved antipsychotic that reduces dopaminergic neurotransmission through D2 partial agonism, not D2 antagonism. (Partial d2 agonist + partial 5HT1 agonist) [b] akathisia; EPS; NMS

Answer 32

- height, weight, BMI, WC - vitals= BP - bloodwork= glucose/HbA1C, lipid profile, liver profile, prolactin - neuro exam for EPS - response to treatment - lifestyle behaviours

Answer 33

* Pre-pubertal children have a higher rate of activating side effects on SSRI * Maturation of pathways impacts effectiveness of medications * Children metabolize medications faster due to larger liver (liver to body ratio) and more efficient glomerular filtration (shorter ½ life) * Higher proportion of water = larger volume of distribution of hydrophilic meds * Less adipose tissues = accumulate lipophilic meds to a lesser extent and consequently eliminate them faster * Increased BBB permeability

Answer 34

* Blood work – 1)CBC, 2)electrolytes, 3)extended electrolytes (Ca + albumin), 4)renal function (Cr. BUN), 5)thyroid function (TSH, T4) * Urinalysis * ECG (\*Guidelines say \>40 years, but we will do it!) * Pregnancy test * Weight, BMI

Answer 35

a) 5-9% b) 3-5%

Answer 36

a) high b) 50% c) 25%

Answer 37

* ADHD is heterogeneous disorder, so likely complex genetic etiologies * Many genes have been linked such as DAT and DRD4

Answer 38

* smoking and alcohol use in pregnancy * low birth weight * psychosocial adversity

Answer 39

* dysfunction of frontal-striatal pathways * dorsolateral and anterior cingulate

Answer 40

* Up to 70% have comorbid psych disorders such as anxiety, depression, ODD, tic, OCD

Answer 41

* Hyperative - 6/9 hyperactive symptoms * Inattentive - 6-9 inattentive symptoms * Combined - 6/9 of each (note in adults, 5/9 needed)

Answer 42

Active ingredient /mode of action/drug interactions Delivery system / onset of action / duration of action Available doses Canadian clinical indications Affordability, accessibility and reimbursement (public/private)

Answer 43

Age and individual variation Duration of effect required by timing of symptoms Concurrent psychiatric and medical issues Physician, family and patient attitudes

Answer 44

a) agranulocytosis= fever, tachycardia, tachypnea, hypotension/blood pressure, examination of oral mucosa ## Footnote b) CBC with differential (absolute neutrophil count)

Answer 45

* Deliberate and purposeful fire setting on more than one occasion. * Tension or affective arousal before the act. * Fascination with, interest in, curiosity about, or attraction to fire and its situational contexts (e.g., paraphernalia, uses, consequences). * Pleasure, gratification, or relief when setting fires or when witnessing or participating in their aftermath. * The fire setting is not done for monetary gain, as an expression of sociopolitical ideology, to conceal criminal activity, to express anger or vengeance, to improve one’s living circumstances, in response to a delusion or hallucination, or as a result of impaired judgment (e.g., in major neurocognitive disorder, intellectual disability [intellectual developmental disorder], substance intoxication). * The fire setting is not better explained by conduct disorder, a manic episode, or antisocial personality disorder.

Answer 46

Baseline (must First 6 months, weekly. Second 6 months, every other week (as long as counts acceptable) After that, every 4 weeks

Answer 47

Hematologic toxicity monitoring: ANC 1,500 to 2,000/mm3: Continue treatment; monitor ANC twice weekly until counts stabilize or increase, then return to previous monitoring schedule. ANC \<1,500/mm3: Discontinue treatment and do not rechallenge patient; continue to monitor WBC/ANC daily until hematologic abnormality is resolved; monitor for signs of infection. If WBC falls \<1,000/mm3 or ANC falls \<500/mm3, place patient in protective isolation with close observation.

Answer 48

a) hypotension, myoclonus/seizures, mental status changes (sedation), sialorrhea b) CBC with differential, clozapine level

Answer 49

a) agitation/irritability excessive movements/excitability impulsivity talkativeness insomnia b) seek medical support/present to ER increased supervision down-titrate ultimately discontinue benzodiazepine

Answer 50

a) * Caucasians, Blacks, Asians – slow metabolizer 2D6 * Blacks and Asians – slow metabolizer 2C19 * East Asians – slow metabolizer 3A4 * Differences in glycoproteins – drug transporter * Polymorphisms of 5HT 2A and D3 receptors – more side effects, including EPS, respond to very low doses * Indigenous and blacks: more risks Db2 b) * Start low, go slow * Close monitoring of SE * FHx of response * Avoid polypharmacy * Regularly reassess need for the medication and dc unnecessary agents

Answer 51

a) Seizure disorder = likley diagnosis in a child with seizures. Most common psych comorbidities in epilepsy: ADHD, ASD, depression, anxiety, psychosis, OCD, PD. (Note answer key = depression) b) Carbamazepine is metabolized by CYP3A4. Fluoxetine inhibits CYP3A4. So the patient will have higher levels of serum Carbamazepine. Side effects could include confusion, ataxia, nystagmus, GI symptoms, SJS. Carbamazepine also cause 1A2, 3A4, 2C19, 2C9 and 2B6 induction which could decrease concentration of fluoxetine But most dangerous/relevant effect is one stated above possibly causing CBZ toxicity

Answer 52

Wellbutrin/ Bupropion (and TCAs)

Answer 53

a) Mirtazapine b) Bupropion, Venlafaxine, SSRIs in some cases

Answer 54

a) Treatment resistant schizophrenia (2 failed antipsychotic trials of at least 6 weeks at midpoint or higher of therapeutic dose range, documentation of adherence, and persistence of 2 positive symptoms with at least moderate severity or a single severe symptom) b) Ileus, Agranulocytosis, Myocarditis, Seizure

Answer 55

* CBC * weekly x 6 months * bi-weekly x 6 months * q4weeks x thereafter \*CAMESA: fasting glucose, insulin, lipid profile, AST/ALT, prolactin (baseline, 3 months, 6 months, 12 months)

Answer 56

a) SSRI (sertraline and fluoxetine) b) Bupropion and TCA

Answer 57

Galactorrhea Gynecomastia Osteopenia/Osteoporosis Sexual dysfunction/Decreased Libido In women - infertility and amenorrhea

Answer 58

Aripiprazole Quetiapine (... and clozapine a distant 3rd, lol)

Answer 59

a) Partial D2 agonist Partial 5HT1 agonist 5HT2A Antagonist b) Less metabolic side effects Less weight gain Less hyperPL c) Akathisia, EPS

Answer 60

* **_Male (2:1)_** * **_Age 20-25_** * AP naive * **_Dose and potency of DA agent_** * **_Hx of NMS (15-20% recur)_** * **IM AP** * **agitation** * **Iron deficiency** * Rapid increase in dose * GDD/ID * FHx catatonia * History of catatonia * polypharmacy * **_physical restraints_** * hyperthermia/fever * hyperT4 * sudden discontinuation of anticholinergic drug * **dehydration** * **Acute medical illness** * Inconsistent use

Answer 61

- instructional interventions= give clear, precise instructions; get the student’s attention before providing instructions; use direct requests (“when-then”) - behavioural interventions= provide immediate and frequent feedback; use visual cues in the classroom or on the desk for transitions; Chunk and break down steps to initiate tasks - environmental intervention= preferential seating away from distractions; proximity to teacher - academic interventions= Actively engage the student by providing work at the appropriate academic level; Permit student to write quizzes, tests and exams in a quiet room - executive function interventions= find a tutor/academic coach; establish a routine - post-secondary interventions= contact the student accessibility/disability centres; allow for extended time on tests/exams

Answer 62

a) DMDD b) ASD ADHD IED ODD/ CD Depression/ anxiety/ BAD Recall, DMDD * Young as 6, up to 18 * Symptoms must be present by age 10 * Can’t be diagnosed with ODD, MDD, BD * Non-episodic irritability

Answer 63

- ADHD is an ongoing condition where BD is episodic - decreased sleep, hypersexuality, grandiosity, hallucinations or delusions, and homicidal or suicidal thoughts and actions occur with childhood mania, but are rare or absent in uncomplicated ADHD.

Answer 64

CD ADHD Adjustment Disorder Adults – ASPD, SUD, Gambling

Answer 65

_Dx:_ \*impulse control disorder (1) The person has set fires deliberately and on purpose on more than 1 occasion (multiple episodes involved) (2) The person feels a tension or affective arousal before setting the fire (3) Fascination, interest, attraction and/or curiosity for fire making paraphernalia, fire fighting equipment or any fire-related topic (4) Pleasure, gratification, or relief may be felt when setting fires, while witnessing a fire or when participating in the aftermath Exclusion criteria: * The fire setting cannot be better explained by another disorder (mania, antisocial personality conduct disorder, other). * The fire setting is not done (1) for monetary gain–insurance etc (2) to express a sociopolitical ideology, (3) to conceal a criminal act, (4) as a conscious expression of anger or vengeance, (5) to improve one's living circumstances, (6) in response to a delusion or hallucination, and (7) as a result of impaired judgement due to delusion or intoxication.

Answer 66

Driver Training * Pharmacotherapy + adherence * Jerome Driving Questionnaire (CADDRA) * Do not use mobile device and minimize distractions * Do not drive at evenings/ night/ weekends * Automatic transmission * Report to MOT if any concerns/ repeated accidents * Curfews * Staying off major highways * Absolutely no drugs or alcohol * PRN use of short acting medication in evenings if necessary

Answer 67

2-4X increased risk of MVC

Answer 68

* **memory and learning** * **executive functions** * **complex attention** * **perceptual and motor functions** * Language * Social Cognition (fyi) Neurodevelopmental immaturities in executive functioning (resulting in problems with attention, impulse control and emotional regulation) combined with a lack of driving experience can lead to problem driving styles in young people in general

Answer 69

- persistent motor or vocal tic disorder (more than 1 year and either motor OR vocal tics but not both) vs provisional tic disorder (less than 1 year) vs Tourette’s disorder (both motor AND vocal tics) - psychostimulant induced - stereotypies/ASD - OCD - PANDAS

Answer 70

A-2 agonists * Guanfacine * Clonidine * Tetrabenzine * Atomoxetine in cases where stimulant is exacerbating tics

Answer 71

* No specific contra-indication for tics+ADHD (Stimulants not containdicated) * Canadian guidelines recommend against cannabinoids, levetiracetam, IVIG, fluoxetine, ondansetron

Answer 72

* Multimodal, non-pharmacological approaches across settings – parent skills training, emotional regulation, anger management, problem solving therapy) * ADHD – stimulant, non-stimulant (a2-agonist and atomoxetine), Risperidone * ASD – Risperidone, Aripiprazole * Not ADHD or ASD – Risperidone

Answer 73

CADDRA: * Stimulant medication is a safe and effective treatment for ADHD + Tic Disorder but requires careful monitoring of potential tic worsening * the alpha-2-adrenergic agonists, clonidine and guanfacine XR, have shown promise in the treatment of tics, particularly in combination with ADHD * In patients where stimulants may cause tic exacerbation, atomoxetine may be also considered as an option as it will rarely cause worsening of symptoms * Methylphenidate long acting – Biphentin, Concerta * Amphetamine long acting – Adderall, Vyvanse * Alpha- agonist – Guanfacine, Clonidine * SNRI – Atomoxetine

Answer 74

* Height * Weight * BP/ HR * ECG is NOT routine * Monitor for cardiac symptoms (by history) * Be alert for signs of misuse, diversion * Symptoms * Side effects

Answer 75

Sudden (cardiac) death Seizures Psychosis * On Vyvanse monograph: * \*\*Potential of abuse/misuse/diversion (only “serious warning”) * Cardiovascular adverse events and sudden death (with structural cardiac abnormalities) * Suppression of growth (and weight loss) * New onset or aggravation of psychotic and manic symptoms * Aggressive behavior or hostility * Suicidal behavior and ideation * Seizures * Tics * Peripheral vasculopathy (Raynaud’s) * Ophtalmo: difficulties accommodation and blurred vision

Answer 76

* Cardiac symptoms including syncope, palpitations, chest pain, shortness of breath or seizures during exercise * Cardiac disease including a clinically significant murmur (not functional, or other symptomatic heart disease * Psychosis * Mania * Seizure * Medical Contraindications * Treatment with MAOI and for up to 14 days after discontinuation. * Glaucoma (narrow angle) * Untreated hyperthyroidism * Moderate to severe hypertension * Pheochromocytoma * Patient Preference Family history * Premature (sudden/unexpected) death in family members \<40 years old * Cardiac history including hypertrophic cardiomyopathy, clinically important arrhythmias including long QT syndrome (LQTS), Marfan syndrome

Answer 77

* Sit in front of the class * Noise cancelling headphones * Break up instructions into small chunks/ step by step * Similarly, break down tasks into small steps * Quiet space for test and evaluations to decrease distractions * More time for test/ assignments/ projects * Body breaks * Transitions – visual aids, warnings about upcoming transition * Eye contact when speaking to the child * Immediate/ frequent feedback (daily report cards) * Access to scribe / minimize note taking * Focus on quality and not quantity * Write down homework * Token economy / positive reinforcement * Access to fidget/sensory objects * Possibility to move without disturbing * Testing on computer or orally if possible * “When… then” * Frequent feedback * Immediate feedback * Sit next to a “more attentive” buddy

Answer 78

DSM 5 * **ADHD** * **Conduct Disorder** * Major Depressive Disorder * Anxiety * Substance Use Disorders (in adults) * Bipolar Disorder * LD/ID \*Increased risk of suicide attempts once other psych disorders controlled for

Answer 79

* #1 - Psychostimulants * #2 – Guanfacine * #3 – Atomoxetine * #4 – Clonidine * #5 – Risperidone * #6 – Valproate

Answer 80

* Tics * ADHD & OCD * Also anxiety, depression, ODD/CD, LD, Bipolar Disorder, SUD

Answer 81

(a) “Refusal”: Anxiety, separation anxiety, social anxiety, phobia, depression, somatization/ somatic symptoms/ IBS, factitious disorder, Panic disorder, PTSD Truancy: Conduct disorder, ODD (b) * Treat underlying anxiety disorder * Consider psycho-ed testing to assess learning needs/barriers * Adapt school work (ie what was missed, where can re-start, etc) / accommodation * Limit secondary gains (no TV or video games at home, etc) * Psychoeducation * Involve caregiver * Gradual Exposure * Multidisciplinary Supports

Answer 82

(a) SUD, CD, PTSD/ trauma, ODD, Adjustment disorder with conduct symptoms, ASD, ID, FASD (b) *Antenatal substance exposure (tobacco and alcohol*); *low birth weight*, *psychosocial adversity*, Lack of stimulation and supervision, Low socio-economic status, depressed mother,

Answer 83

CD + 2 of the following * Lack of remorse/guilt * Callous/lack of empathy * Unconcerned about performance * Shallow/deficient affect

Answer 84

* Parenting skills training (Incredible Years) * School adaptations/ accommodations * Functional assessment * Positive reinforcement * Psychoeducation * Anger management skills; emotional regulation skills * Treatment of comorbidities * Social skills training * Vocational support

Answer 85

* Multimodal, non-pharmacological approaches across settings – parent skills training, emotional regulation, anger management, problem solving therapy) * ADHD – stimulant, non-stimulant, Risperidone * ASD – Risperidone, Aripiprazole * Not ADHD or ASD – Risperidone

Answer 86

Childhood-Onset Fluency Disorder (Stuttering) * sensory deficits (assess hearing), normal speech dysfluencies, secondary to meds, adult onset dysfluencies, Tourette * SLP assessment – language (productive, receptive), verbal fluency, phonation, social pragmatic use of language * Are there any concurrent difficulties? Coordination, ID, etc… * Comorbidities

Answer 87

ASD, ID, language disorder, LDs, speech sound disorder, childhood-onset fluency disorder, social communication disorder, hearing impairment

Answer 88

sensory deficits (assess hearing) normal speech dysfluencies secondary to meds adult onset dysfluencies Tourette

Answer 89

* SLP Treatment with involvement of parents * [Cognitive behavioural therapy](https://www.psychdb.com/psychotherapy/cbt) can also be used to identify thoughts processes that worsen stuttering, and to identify coping strategies related to stress from stuttering. * Electronic delayed auditory feedback tools can also be used to help individuals to slow down their speech.

Answer 90

* Question - The persistence and frequency of these behaviors should be used to distinguish a behavior that is within normal limits from a behavior that is symptomatic. * Mood at practice, relation to peers, respect of authority/adults, frustration tolerance, tantrums (frequency and duration) * Other dx to consider - ADHD, LD

Answer 91

* Conners * SNAP-IV Teacher and Parent Rating Scale * ASRS (Adult ADHD Self-Rating Scale) * WFIRS-P (Weiss Functional Impairment Rating Scale-Parent) * WFIRS-S (Weiss Functional Impairment Rating Scale-Self) * WSR II (Weiss Symptom Record II) * CADDRA Teacher Assessment Form * CADDRA Clinician ADHD Baseline/Follow-Up Form * CADDRA Patient ADHD Medication Form

Answer 92

1. Non-stimulant medications 1. Atomoxetine, Guanfacine 2. Long Acting Stimulants 1. Vyvanse – pro (inactive) drug that requires first pass metabolism, so it cannot be injected 2. Other long-active stimulants (ie: Concerta/ OROS)

Answer 93

CADDRA and CANMAT Bipolar Guidelines (Children & Adolescents) 1. Hyperactivity/distractibility are chronic and not episodic 2. Insomnia is present but need for sleep is unchanged 3. Grandiosity is not present 4. No psychosis

Answer 94

a) Stimulant medication – methylphenidate, amphetamine (Health Canada approved for age 6+); long acting stimulant with shorter duration of action (e.g., biphentin – methylphenidate controlled release) b) Sleep problems (Pre-schoolers metabolize methylphenidate more slowly than school age children (AACAP PP) Higher rate of emotional adverse events (crabbiness, irritability, proneness to crying) – AACAP PP

Answer 95

a) Child factors: - Increased symptom severity - Combined subtype - Comorbidities - Fewer side effects - Long-acting formulation b) Family factors: - Belief that medication is safe - Belief that ADHD is neurobiological disorder - Good relationship with doctor Parent-Physician Relationship Factors: - Parental trust in healthcare provider - Shared decision making

Answer 96

(a) Methylphenidate, Amphetamines, Alpha-2 agonist (Guanfacine, Clonidine), SNRI (Atomoxetine) (b) Monitor for new or worsening tics with psychostimulants. Some resources indicated AMPH may be worse than MPH in increasing tics.

Answer 97

a) **Sleep-Related effects of stimulants** - Insomnia (delayed sleep onset latency \>30 minutes) - Reduction in Slow Wave and REM Sleep - Increased wakefulness during the sleep period b) **Sleep Disorders** - Insomnia - Circadian Rhythm Sleep-wake Disorder (Delayed sleep phase) - Restless leg syndrome - OSA

Answer 98

DDx: 1. ADHD – but this is a neurodevelopmental disorder 2. Adjustment disorder with disturbance of conduct 3. ODD 4. Attachment disorder (Reactive Attachment Disorder or Disinhibited Social Engagement Disorder) 5. PTSD

Answer 99

Parent Child Interaction Therapy Parent Management Training (Incredible Years, Triple P)

Answer 100

Psychoeducational testing (to rule out LD) mood and anxiety suspensions/expulsions/conduct disorder behaviours quality of social relationships

Answer 101

SNAP-IV Conners

Answer 102

Increased HR and BP Appetite suppression and weight loss GI upset Dry mouth Headache Anxiety/Irritability Initial insomnia Rebound effect

Answer 103

Duration of action of stimulant redistribute caloric intake once stimulant wears off start low and go slow dose reduction monitor vitals minimize other sympathomimetic agents (caffeine)

Answer 104

Growth suppression (MTA Study: 1cm/year for first two years and no difference in 3rd year; 1-2 cm adult growth less when treated for 10 years; benefits of treatment generally outweigh the risk)

Answer 105

Any methylphenidate or amphetamine based stimulant medication provided seizures are well controlled by antiepileptic medication FYI - Higher incidence of ADHD in kids with epilepsy (than gen pop) - Higher incidence of epilsepy in kids with ADHD (than gen pop) - When kid has ADHD, epilepsy can more severe - No evidence that stimulants psychostimulants increase the severity or frequency of seizures in patients with stable epilepsy. - Consider drug ineractions Carbamazepine– Methylphenidate: decrease Meth Phenytoin, Phenobarbital – Methylphenidate: increase anticonvulsant Carbamazepine, Phenytoin, Pheno – Guanfacine: decrease Guanfacine (3A4)

Answer 106

Irritability “Rebound” - Symptoms return or appear worse than when treated (CADDRA)

Answer 107

Initation Ability to complete multi step tasks Organization Planning Self-directed activity

Answer 108

1. Inattention and hyperactivity in preschoolers can be influenced by a number of factors. These can include intellectual impairment, expressive language issues, and their response to child abuse and neglect as well as conflictual environments 2. American Academy of Pediatrics has suggested that ADHD can be diagnosed in children as early as age four 3. Nonpharmacological approaches should be first-line treatment

Answer 109

Parent management training – Incredible Years or Triple P Positive Parenting Program Parent-Child Interaction Therapy

Answer 110

Higher rate of emotional adverse events (crabbiness, irritability, proneness to crying) – AACAP PP Insomnia (slower metabolism of methylphenidate) Decreased appetite and weight loss (most serious) Paradoxical agitation/ irritability/ anxiety Emotional outbursts

Answer 111

ADHD LDs SUD

Answer 112

* Conners, SNAP-IV, * For LD maths: o WIAT (Wechsler Individual Achievement Test) o Keymath diagnostic arithmetic test

Answer 113

Child: - mood lability, irritability (instead of sadness as DSM criterion) - low frustration tolerance, temper tantrums - somatic complaints - social withdrawal - mood congruent auditory hallucinations - Fewer melancholic symptoms - Fewer delusions and suicide attempts - Less likely to verbalize feelings of depression/anhedonia than adults Adolescent – - more melancholic symptoms and suicide attempts than children - more hypersomnia and hyperphagia (DSM-5) - more pervasive anhedonia (K&S) - psychomotor retardation - more mood reactivity and may seek out activities for temporary improvements in mood (AACAP)

Answer 114

_First Line_ lithium (level 1) risperidone (level 1) aripiprazole (level 2) asenapine (level 2) quetiapine (level 2) (Risperidone may be preferable to lithium for non‐obese youth, and youth with ADHD)

Answer 115

**General symptoms of low-grade lithium toxicity:** weakness tremor (new-onset or worsening) mild ataxia poor concentration tinnitus nausea diarrhea **More significant toxicity** vomiting gross/coarse tremor slurred speech confusion nystagmus disorder dysarthria lethargy If not treated, it may lead to seizure (tonic-clonic), coma, neurological damage, and death.

Answer 116

ADHD Mania Neurodevelopmental **Not** None **Insomnia** None Hyper verbose Not **Episodic** Psychosis **Decreased need for sleep** Elation, grandiosity Flight of ideas

Answer 117

Children’s depression rating scale Children’s depression inventory Mood and feelings questionnaire Center for Epidemiological Studies Depression Scale for Children (CES-DC)

Answer 118

CBT, IPT, internet-based psychotherapy

Answer 119

* **No need for any work-up pre-SSRI unless there is special concern OR rule out a physical health cause** re: ECG (already on other QTc prolonging agents) and Na (PHx) * If indicated: b-hCG, tox screen, relectrolytes?

Answer 120

major depressive disorder substance use withdrawal (alcohol, amphetamines, cocaine) obstructive sleep apnea hypothyrodisim circadian rhythm sleep-wake disorders

Answer 121

**safety concerns (suicidal, homicidal, mental health is impairing patient’s ability to care for themself/is at risk of causing serious physical impairment of patient)** psychotic symptoms catatonic features -oor nutritional intake, putting patient’s physical health at risk failure of outpatient treatment

Answer 122

* Fluoxetine * Many RCT, well tolerated, works, relatively stable serum levels due to long half-life * long half life lessens the impact of nonadherence\* PP

Answer 123

* Early onset, sudden onset * Mood congruent psychosis * FHx of BAD * Psychomotor retardation * Mania/ hypomania on AD * Mixed symptoms, labile mood * Atypical Depression (Hypersomnia, hyperphagia) * Emotional/Behavioural Dysregulation

Answer 124

Social isolation awareness of deficits (level 1) FHx sudden loss stress at home or at school alexithymia low self-esteem ACEs/ abuse higher cognitive functioning, capacity for introspection stressful life events quality of social relationships

Answer 125

high functioning autism Physical and sexual abuse bullying Factors inherent to their diagnosis (deficit in expression of feelings and thoughts) Factors pertaining to the general population (abuse, depression, anxiety, etc.).

Answer 126

* In **grief** the predominant affect is **feelings of emptiness and loss**, while in an **MDE it is persistent depressed mood** and the inability to anticipate happiness or pleasure. * **Dysphoria in grief is likely to decrease** in intensity over days to weeks and occurs in waves, **“pangs of grief”** associated with thoghts/memories of deceased * Depressed **mood of an MDE is more persistent** and not tied to specific thoughts or preoccupations. * **Pain of grief may be accompanied by positive emotions** and humor that are uncharacteristic of MDE. * The t**hought content associated with grief - preoccupation with thoughts and memories of the deceased**, rather than the s**elf-critical or pessimistic ruminations** seen in an MDE. * In **grief, self-esteem preserved** * In **MDE feelings of worthlessness** and self-loathing are common. * If self-derogatory ideation is present in grief, it typically involves perceived failings vis-à-vis the deceased * In **grief, thoughts about death and dying generally focused on the deceased** and possibly about “joining” the deceased * In **MDE** such thoughts are focused on **ending one’s own life because of feeling worthless**, undeserving of life, or unable to cope with the pain of depression.

Answer 127

* Pre-pubertal children have a higher rate of activating side effects on SSRI * Maturation of pathways impacts effectiveness of medications * Children metabolize medications faster due to larger liver (liver to body ratio) and more efficient glomerular filtration (shorter ½ life) * Higher proportion of water = larger volume of distribution of hydrophilic meds * Less adipose tissues = accumulate lipophilic meds to a lesser extent and consequently eliminate them faster * Increased BBB permeability

Answer 128

* thyroid function tests * urinalysis * creatinine/Urea * serum calcium levels * pregnancy test in female adolescents * complete blood cell counts Once a stable lithium dose is obtained, lithium levels, renal and thyroid function, and urinalyses should be monitored regularly (every 3-6 months)

Answer 129

· Rapid symptom onset · Mood-congruent psychotic features · Psychomotor retardation · AD (medication-induced) activation/ hypomania/ mania

Answer 130

a) SSRI b) Bupropion and TCA

Answer 131

* Adjustment Disorder, MDE * OCD * PTSD * GAD, SAD * Clinical High Risk Psychosis

Answer 132

* Presence of Depressive and Other Comorbid Psychiatric and Medical Disorders * Functional impairment, clarify baseline function * Safety – SI, intent, plan, gestures, SH, HI * Evaluate child and family’s strengths, supports and protective factors * Presence of Ongoing or Past Exposure to Negative Events, the Environment In Which Depression Is Developing, Support, and Family Psychiatric History Other (not in the PP) - Psychosis - Capacity for consent

Answer 133

Aripiprazole Lithium Divalproex Lamotrigine adjunct (age 13+)

Answer 134

Accutane (Isotretinoin) Steroids Methotrexate OCP Anticonvulsants (Levetiracetam/Keppra)

Answer 135

Parents or other caregivers should be included in the evaluation Child biological father school CAS

Answer 136

TF-CBT (first line; most evidence. PRACTICE components) Other trauma-focused psychotherapies: (Child-parent psychotherapy Psychodynamic trauma-focused therapy EMDR (Katzman)) SSRIs can be considered for PTSD or for comorbidities with PTSD (Sertraline alone or as adjunct to CBT is not more effective than placebo and cannot be recommended – Katzman) Medications other than SSRIs can be considered (sleep, nightmares) School-based accommodations

Answer 137

* TF-CBT (first line; most evidence. PRACTICE components) * Other trauma-focused psychotherapies * Child-parent psychotherapy * Psychodynamic trauma-focused therapy * EMDR (Katzman) * Psychoeducation * Relaxation training * Affective modulation skills * Cognitive coping and processing * Trauma narrative * In-vivo mastery of reminders * Conjoint child-parent sessions – engage caregiver, regain sense of control, improve attunement/ communication,

Answer 138

* May not have flashbacks but often have trauma expressed through play - repetitive play, trauma themes, trauma-specific re-enactment * Nightmares – may be without trauma-specific content * May have new aggression, oppositional behaviour * May have new separation anxiety, new fears not obviously related to traumatic event (fear of the dark) * Developmental regression (toileting and speech) * In adults, avoidance may be of memories, thoughts and feelings; in children it is exclusively external reminders * Specific subtype of PTSD for children \<6 in DSM-5 without criteria for cognitive distortions, memory of event, or avoidance of memories/thoughts/feelings

Answer 139

* Propranolol, Morphine, SSRI * To *prevent*, none is approved (anxiety guidelines 2014) * Propranolol: conflicting evidence (improved on parent reports but not child report) * Morphine: cohort studies suggest it might be helpful

Answer 140

* Trauma-focused CBT – stabilization, integration of trauma, reconnection * PRACTICE – psychoeducation/ parenting skills; Relaxation skills; Affective modulation skills; Cognitive coping and processing; Trauma narrative; In vivo master of trauma reminders; Joint child-parent sessions; Enhancing future safety.

Answer 141

- markedly diminished interest or participation in significant activities - persistent negative emotional state - exaggerated startle response - hypervigilance - problems with concentration

Answer 142

Trauma-focused CBT: * Phase 1 – stabilization – affect regulation, coping * Phase 2 – integrate traumatic memories – re-experience symptoms * Phase 3 – reintegration/ maintenance – consolidation and resilience PRACTICE * Psycho-education * Relaxation techniques * Affective modulation skills * Cognitive coping and processing * Trauma narrative * In vivo mastery of triggers/reminders * Conjoint sessions with parents * Enhance future safety

Answer 143

Family (bio family, foster family)/caregivers School CAS

Answer 144

Propranolol Morphine

Answer 145

Alpha -1 – blocker - Prazosin

Answer 146

a) Clonidine, guanfacine (may reduce intrusive and hyperarousal symptoms in children with PTSD symptoms) Prazosin (Dyssomnias, including nightmares and frequent nighttime awakenings) SSRIs (not efficiacious in children, but could be used in adolescent with co-occurring MDD or anxiety) b) Benzodiazepines

Answer 147

Maintain – secure attachment, peer relationships, routines/ predictability Child and Family Traumatic Stress Intervention (CFTSI) Pyschological First Aid Caring adults (parents, teachers, and health professionals) to reassure children Encourage (but not press) them to express their feelings Normalize disaster reaction Address fears, worries and cocnerns as they arrive Help them to resume normal roles and routines Help parents and teachers identify acute stress responses. \*POTENTIALLY morphine (burns) + propranolol Nightmares – Prazosin

Answer 148

* *PRACTICE** mnemonic (Lewis) TF-CBT * *P**sychoeducation and **P**arenting Skills Training * *R**elaxation * *A**ffective modulation skills * *C**ognitive coping and processing * *T**rauma narrative * *I**n Vivo mastery of trauma reminders * *C**onjoint Child-Parent sessions * *E**nhancing future safety and development

Answer 149

No body image disturbance in ARFID and No fear of weight gain in ARFID

Answer 150

Sensory aversion choking episode repeated emesis traumatic GI investigation reflux PCRP

Answer 151

In binge eating, there is no compensatory behaviour to avoid weight gain.

Answer 152

Fluoxetine Some evidence for TCA, topiramate, sertraline and citalopram NOTE: contraindication for bupropion (Sz)

Answer 153

Pre-planned meal plan (determined by parents) Max 20min for mealtime. Substitutions/ supplementation if unable to complete nutrition as presented. Distractions – during and after meal. Externalize the ED. Providing validation and support

Answer 154

AACAP PP: 1. Eating Disorder Examination Questionnaire (EDE-Q) 2. Eating Disorder Inventory (EDI) 3. Eating Attitudes Test (EAT) Validated in younger children: 4. Kids’ Eating Disorder Survey (KEDS) 5. Child EDE-Q 6. EDI-Child 7. Child-Eating Attitudes Test (CHEAT)

Answer 155

*Dieting to try to accomplish thin ideal physique leading to physiological starvation and hunger, promoting binge eating and followed by guilt and fear of weight gain leading to purging* **Genetics** **Abuse, PTSD** **Social pressures to be thin** Body dissatisfaction Negative affect

Answer 156

Genetics and family history of mood, anxiety, SUD, cluster B Idealization of thinness and dieting Early menarche Childhood obesity Volatile family environment or history of abuse Temperament novelty seeking, impulsivity, affective instability Female Sex

Answer 157

Criterion A An **eating or feeding disturbance** (e.g. - apparent lack of interest in eating or food; avoidance based on the sensory characteristics of food; concern about aversive consequences of eating) as manifested by **persistent failure to meet appropriate nutritional and/or energy needs** associated with at least 1 of the following: * Significant weight loss (or failure to achieve expected weight gain or faltering growth in children) * Significant nutritional deficiency * Dependence on enteral feeding or oral nutritional supplements * Marked interference with psychosocial functioning Criterion B The disturbance is **not better explained by lack of available** food or by an associated culturally sanctioned practice. Criterion C The eating disturbance **does not occur exclusively during the course of anorexia nervosa or bulimia nervosa**, and there is no evidence of a disturbance in the way in which one's body weight or shape is experienced

Answer 158

Stabilize the patient from a physical health perspective ...Once this has occurred, next steps can be taken 1. -**Target precipitating event** that triggered ARFID eg. anxiety related to choking, treated with CBT and/or pharmacotherapy such as an SSRI 2. If ARFID is related to **family conflict**, this could be managed via family based therapy, CBT, psychoeducation, parent psychoeducation 3. If ARFID related to **sensory aversion**, consider a **food hierarchy** or food chaining

Answer 159

Phase I: weight restoration via psychoeducation, externalizing illness, raising anxiety, parents take control of eating Phase II: Returning control over eating to the adolescent gradually Phase III: review of progress, return to normal family life, identifying potential challenges

Answer 160

\<75% IBW heart rate \<50 (during the day); \<45 (at night) systolic BP \< 90 arrhythmia orthostatic changes= \>20 BPM HR; \>10mmHg BP refusal to eat ongoing weight loss despite intensive management hypothermia (\<36)

Answer 161

syncope hematemesis hypokalemia (\<3.2) low Cl (\<88) arrhythmia failure to respond to outpatient treatment esophageal tear

Answer 162

Depression (50%) Panic Disorder Alcohol, Substance Abuse Cluster B Personality Disorder – BPD Traits – perfectionism, harm avoidance, novelty seeking, impulsive, affective instability

Answer 163

CBT modified for BN IPT Fluoxetine Also – tricyclics, topiramate, sertraline, citalopram

Answer 164

Depression (50%) OCD (30%) Cluster C Personality – OCPD Traits – perfectionism, harm avoidance

Answer 165

a) refeeding syndrome b) * Gradual refeeding, monitor K, P and Mg * Treatment: * reduce caloric intake * evaluate cardiovascular function (ECG monitoring) * monitor closely (Check P daily for 5 days, then q2 days for 3 weeks) * If necessary, supplement with P (correct electrolyte anomalies and mineral deficiencies (IV, PO4 supp, K supp, thiamine, multivitamins)) * Pediatrician involved

Answer 166

a) Admit for medical stabilization b) Unstable vitals

Answer 167

* Complex and polygenic for OCD * Genetic loading has a significant impact on risk of developing condition * 1st degree relative of OCD pt 4x as likely to develop OCD * 5HT2A (serotonergic) and SLC1A1 (glutamate) are implicated OCD

Answer 168

* MZ concordance 80-87% * DZ concordance 47-50% * ½ of phenotypic variation due to genetics * 1^st degree relative of OCD pt 4x as likely to develop OCD * Relatives of childhood-onset OCD are 30 x more likely than relatives of those without OCD to be diagnosed with the disorder * * Ordering and hoarding  more genetic * Genetic studies most often implicate genes for 5ht and glutamate regulation

Answer 169

ASD OCD Neurodevelopmental Egosyntonic Stereotypies Socio-emotional difficulties Communication/ language and non-verbal difficulties Chronic, pervasive rigidity/concreteness Not Egodystonic Compulsions to decrease anxiety Not Not Rgidity re: obsessions/ compulsions

Answer 170

* Trichotillomania * Telogen Effluvium / Alopecia due to... * GMC (autoimmune, low iron, hypothyroid) (Telogen effluvium) * Meds like VPA, antithyroid agents, hormones, anticonvulsants, anticoagulants, beta blockers, angiotensin-converting enzyme inhibitors, and lithium. * OCD * ASD * Dermatologic Alopecias * Telogen effluvium * Tinea capitis * Traction alopecia * Alopecia areata * ID – stereotypies * Body Dysmorphic Disorder * NSSI * Normal behaviour/ intentional hair removal

Answer 171

HRT – (a) awareness training – such as triggers (b) competing response training – replacement behaviour (c) motivation and compliance – cons list, positive reinforcement (d) relaxation training – to help prevent the behaviour (e) generalization training

Answer 172

**CBT (ERP) is first line.** **Second line is CBT in combination with SSRI** (Sertraline, Citalopram, Fluoxetine, Fluvoxamine). You may consider augmentation with Risperidone or Aripiprazole. Third line is CBT with Clomipramine. (In moderate to severe OCD, inadequate response to CBT (ERP), patient preference (refusal of psychotherapy) or patient is \>12yo – you may (should) consider combination treatment.)

Answer 173

**AN**, **Depression,** LD, psychosis, BAD, depression, hoarding ODD, Tics, ADHD *associated with worse response to meds*

Answer 174

Obsessions - **Contamination/ germs/ getting sick**; something bad happening; **thing being “just right”**; sexual.

Answer 175

Compulsions - Washing/ cleaning/ disinfection; arranging/ ordering/ repeating until “just right”; checking/ symmetry.

Answer 176

a) **_Habit reversal training_** **-** primary treatment for trichotillomania. How to recognize situations (urges/ preceding thoughts and emotions) where you are likely to pull your hair and how to substitute other behaviors instead (which may include relaxation and mindfulness techniques). For example, you might clench your fists to help stop the urge or redirect your hand from your hair to your ear. b) **_Cognitive therapy_** - This therapy can help you identify and examine distorted beliefs you may have in relation to hair pulling. Cognitive restructuring. c) **_Relaxation training_** (progressive muscle relaxation) d) _Acceptance and commitment therapy_ - can help you learn to accept your hair pulling urges without acting on them. e) Exposure and response prevention (ERP)

Answer 177

Fluoxetine Sertraline Fluvoxamine Clomipramine

Answer 178

**Time** occupied by obsessive thoughts **Interference** due to obsessive thoughts **Distress** associated with obsessive thoughts **Resistanc**e against obsessions **Degree** of control over obsessive thoughts Time spent performing compulsive behaviours Interference due to compulsive behaviours Distress associated with compulsive behaviours Resistance against compulsions Degree of control over compulsive thoughts

Answer 179

HRT – (a) awareness training – such as triggers (b) competing response training – replacement behaviour (c) motivation and compliance – cons list, positive reinforcement (d) relaxation training – to help prevent the behaviour (e) generalization training

Answer 180

**Operant conditioning**: process of learning through reinforcement and/or punishment **Positive reinforcement**: response or behavior is strengthened by rewards, leading to the repetition of desired behavior. The reward is a reinforcing stimulus. **Negative reinforcement**: the termination of an unpleasant state following a response.Negative reinforcement strengthens behavior because it stops or removes an unpleasant experience. **Punishment**: an aversive event that decreases the behavior that it follows.

Answer 181

HC – Clomipramine (10+) FDA – Sertraline (6+), Fluoxetine (7+) and Fluvoxamine (8+)

Answer 182

A pattern of behavior in which a child a**ctively approaches and interacts with unfamiliar adults** and exhibits a**t least two of** the following: 1. Reduced or **absent reticence** in approaching and interacting with unfamiliar adults. 2. **Overly familiar** verbal or physical behavior (that is not consistent with culturally sanctioned and with age-appropriate social boundaries). 3. Diminished or **absent checking** back with adult caregiver after venturing away, even in unfamiliar settings. 4. **Willingness** to go off with an unfamiliar adult with minimal or no hesitation. Behaviors in Criterion A are not limited to impulsivity (as in attention-deficit/hyperactivity disorder) but include socially disinhibited behavior. Child has experienced a **pattern of extremes of insufficient care** as evidenced by **at least one** of the following: 1. Social **neglect** or deprivation in the form of persistent lack of having basic emotional needs for comfort, stimulation, and affection met by caregiving adults. 2. Repeated **changes** of primary caregivers that limit opportunities to form stable attachments (e.g., frequent changes in foster care). 3. **Rearing in unusual settings** that severely limit opportunities to form selective attachments (e.g., institutions with high child-to-caregiver ratios) Child has **developmental age of at least 9-months**

Answer 183

_In general:_ * May approach unfamiliar adults without any fear; * May seek comfort from unfamiliar adults; * Wander away from caregiver without checking back * Attaches indiscriminately * Attention seeking, shallow, superficial interpersonally * “impulsive-type behaviors”, attention-seeking and more shallow relationships

Answer 184

_Management approach:_ * Safety! (especially of current placement) * Ensure they are provided with an emotionally available attachment figure. * Dyadic therapist such **as Circle of Security, Parent Child Interaction Therapy (PCIT**), Dyadic developmental psychotherapy (DDP)), **Attachment and Biobehavioural Catch-up (ABC)**, Video-based Intervention to Promote Positive parenting (VIPP), Child-Parent Psychotherapy * Limit contact with noncaregiving adults (young children) * Adjunctive interventions for children who display aggressive/oppositional behaviour No therapeutic holding, "rebirthing" or other such nonsense.

Answer 185

Attachment disorder – Reactive Attachment Disorder and/or DSED

Answer 186

Do not seek comfort from or interaction with caregivers. Do not feel reassured by caregivers/ difficult to calm/ reassure. Agitation. Mood lability. Temper tantrums. Reduced emotional responsiveness. Restricted positive affect/ superficiality of affect. Indiscrimination of attachment figures. Unstable interpersonal relationships. Lack of empathy. Impulsivity.

Answer 187

Symptoms of **Reactive Attachment Disorder** tend to **disappear** once placed in foster care or adopted. Symptoms that are **unlikely to remit** despite adequate placement are linked to **DSED** Children: indiscrimination, no safety base, familiarity Teen: superficial, shallow or frequently changing interpersonal relations and interpersonal conflicts

Answer 188

At daily/each assessments if making threats or reporting ideation with any mental status change before passes/going off unit before discharge

Answer 189

HI physical impairment elopement risk risk of substance use driving boundaries around interactions with other patients risk of harm to others

Answer 190

Stigmatization developmental perspective need a longitudinal assessment sometimes subjective to make assessment perception that they are “untreatable”

Answer 191

appropriate treatment/ intervention validation psychoeducation avoid unnecessary treatments/ pharmacotherapy/ side effects stop contributing to auto-stigmatisation

Answer 192

ODD CD IED DMDD

Answer 193

Social Anxiety GAD MDD

Answer 194

* Safety at school (social-emotional and physical safety owing to standards and rules, prevention of bullying/intimidation), * connectedness to school * Relationship/interaction between teacher and student * Learning environment at school

Answer 195

* NSSIB = not suicide attempt but maladaptive coping strategy * Inpatient admission is not helpful and may actually result in further regression of distress tolerance/ emotional regulation skills. * This learning is done in the community.

Answer 196

* Minimize alcohol/ substance use * Skills * Emotional regulation skills * Improve communication * Distraction * Interpersonal effectiveness * Problem-solving skills * Conflict management Skills * Affective Language Skills * Psychotherapies * DBT * CBT (Individual, Family, Parent Training) * FBT-Attachment for SI * IPT – Individual for SI * Psychodynamic therapy-Individual + Family * Safety Planning * Parent Skills Training * Keep environment safe Also Acceptable Answers: * Interpersonal relationships/ supports * Try to remove reinforcements/social contingencies * Recognize warning signs * Develop coping strategies (ex TIPP) * Use friends, family and MH professionals for support * Keep environment safe * Motivational interventions/brief intervention * Use mobile safety planning apps * Mentalization-based treatment? * Affective language skills * Self-soothing skills * Psycho-education for patient and family * Cognitive problem-solving skills

Answer 197

1. Where there any co-ingestions/ concurrent substance use? 2. Was this a suicide attempt? (Clarify SI/ intent/ plan/ access to means (including guns)) 3. History of previous SA 1. Precipitants - stressors, triggers 2. Protective factors – supports, plans, evidence of future orientation 3. Do you live alone? 4. Are you still thinking of suicide?

Answer 198

**a) SI, plan, intent, access to means, future orientation** **b) Triggers/ precipitants/protective factors** **c) History of previous SA** **d) Collateral history** **e) Psychiatric diagnoses/comorbidities** f) Protective/ resiliency factors (ex: family, pets, religion) g) Supports (ex : formal and informal) h) Collateral information i) Family history (of suicidality and mood d/o) j) History of abuse, violence, bullying k) Substance use l) Exposure to suicide (ex. in media or friends/school) m) Emotional/cognitive factors: hopelessness, helplessness, impaired problem-solving, agitation, despair, low SE, impulsivity n) Familial conflict o) If part of minority (first nation, lgbtq, …)

Answer 199

**a) Distress tolerance skills** **b) Emotional regulation skills** **c) Distraction** d) **Remove “means” – sharps, lighters, etc…** e) Anger management f) Problem solving approach g) Supports h) Interpersonal effectiveness, friendships i) Mindfulness, relaxation strategies

Answer 200

* Is this patient medically stable? ABC – vitals, LOC, QTc + involve other specialties as needed * Assess Safety (+ Patient status in hospital – voluntary vs. involuntary) * Assess for possible admission

Answer 201

Distraction (holding ice, cold shower) Distress tolerance (TIPP= temperature, intense exercise, pace breathing, progressive muscle relaxation) Emotion regulation techniques Removing sharps and lethal means, and safety proofing home Treat comorbidities Meditation Mindfulness

Answer 202

Delayed sleep-wake phase disorder (DSWPD)

Answer 203

Melatonin is a hormone with chronotropic effects. Can advance or delay sleep phase depending on when it is taken. Light sedative effects.

Answer 204

Stimulants may contribute to: initial insomnia/increased sleep latency decreased overall sleep decreased REM sleep increased restlessness

Answer 205

* Anchoring a wake time (even on weekends; max 2 hours difference between week and weekend) * Melatonin * Avoid naps * Avoid caffeine, chocolate and other stimulants * Avoid screens/ blue light * No exercise within 2 hours of desired sleep time * Bedtime routine, low stimulation * Remain in bed only for sleep * Bright light in the morning, such as SAD lamp * CBTi

Answer 206

URGE – **urge** to move legs worse with **rest** **gets** better when move around worse in **evening**

Answer 207

Gabapentin Clonidine Clonazepam Avoid caffeine and SSRI Iron supplements if ferritin \<50mcg/L \*\*(dopamine agonists like pramipexole for adults not children)

Answer 208

**Involvement of parents** - to educate them, support the adolescent’s treatment, sometimes work on the interpersonal problem area in dyadic sessions with the adolescent. **Limited sick role** - Doing the activity but revising expectations, recognize performance may fall below the predepression level. Therapist reassures pt things will get better when depression improves **Discussion within areas relevant to adolescence** **Techniques employed in the treatment geared towards adolescents** (rating scales 1-10, more basic social skills work, perspective-taking skills, negotiation with parents) **12 weeks instead of 16 weeks**

Answer 209

* Depression * Persistent Depressive Disorder * Adjustment disorder (IPT for BN only in adults)

Answer 210

Precontemplation Contemplation Preparation Action Maintenance Relapse

Answer 211

**Develop discrepancy between current behaviour and desired behaviour** **Roll with resistance** Exploring ambivalence about change Express empathy Develop autonomy Avoid arguments and confrontation – resist the “righting” reflex Support self-efficacy/ empower the patient **Open ended questions + Validate + Reflect + Summarize**

Answer 212

**Universality, identification, normalization** **Interpersonal skills training** **Exposure therapy** Cohesion Hope, supportive environment Validation Role modelling Motivation

Answer 213

(Yalom) Instillation of Hope Universality Imparting Information Altruism The corrective recapitulation of primary family group Development of socializing techniques Imitative behvaiour Interpersonal learning Group cohesiveness Catharsis Existential Factors

Answer 214

Similarities – short-term, 16-20 sessions, chases affect, role-plays, therapist led; developed for research on depression CBT IPT * **Link between thoughts, actions and emotions** * Socratic questioning, collaborative empirical approach * **No sick role** * May have multiple goals * *Automatic thoughts/ cognitive restructuring* * *Operant conditioning* * **Homework** * **Link between emotions and interpersonal relationships** * Specific work on the link to changes in relationships vs. changes in symptoms * **Limited sick role** * *4 areas of focus – grief/ loss, interpersonal deficits, transition and interpersonal disputes* * *Interpersonal inventory/ closeness circle/ communication analysis* * Rooted in attachment theory * Interpersonal experiments

Answer 215

* In general = Develop discrepancy + Deal with resistance + Express empathy + Develop Autonomy + Support Self-Efficacy * He seems to be in the “preparation” stage of change = pro/cons list; outline goals; smart goals and how will maintain goals; contingency planning; psychoeducation re: relapse.

Answer 216

**Skills transition to home** **Adherence to treatment** Therapeutic alliance Alignment of goals Modification of environmental factors Validation and support Collateral information Psychoeducation

Answer 217

**Psychoeducation** **Progressive exposure** to trigger (ie: photos of bees) + relaxation techniques Regulation of emotions, problem solving, cognitive restricting **Use more visuals;** repetition; collateral/ increased involvement from parents Incorporate **more ABA principles**? Functional behavior analysis Use **child’s talents** and special interests **Frequent movement breaks** or sensory activities More **repetitive, more visual, more concrete** Ex. instead of naming level of anxiety 1-10, drawing in on thermometer

Answer 218

Language barrier Financial barriers (access to transportation, baby-sitting, etc) Stigmatization Difficulty navigating the system Systemic biases/ racism/ discrimination Cultural factors – patient factors and practitioner factors; interpretation of symptoms; idioms of distress; cultural/ religious models of disease; different coping and help-seeking behaviours.

Answer 219

* **Involve all systems in treatment (school, community, etc)** * **Intensive treatment with case management (contacts at least once a week, usually more, usually just 4 families/case load)** * **24/7 Availability with on call system** * Present-focused, action-oriented and well-defined – what are the contributiong factors to behvaiour? * Increase skills of parents and their self-efficacy to manage their child

Answer 220

Serious juvenile offenders with possible SUD, and their families

Answer 221

Everywhere – home, community, institution

Answer 222

Absences/lateness Splitting (therapist) Silence/ superficial subjects Acting Out Not completing homework Social withdrawal No progress

Answer 223

Bowen Family Systems: Differentiation of self Triangulation Emotional cutoffs Family emotional system Sibling position

Answer 224

Problem Solving Communication Roles Affective Responsiveness Affective Involvement and Behavioral Control.

Answer 225

* **Avoid misdiagnosis** * **To obtain useful clinical information** * **Improve clinical rapport and engagement** * **Clarify cultural epidemiology** * **Improve therapeutic efficacy** * To guide clinical research * Improve treatment adherence * Understand precipitants, perpetuating factors, stressors

Answer 226

loss transition immigration

Answer 227

* Ddx – *selective mutism, social anxiety,* learning a new language, communication disorder, ASD, *adjustment disorder,* MDD, “other cultural syndromes – cultural conceptualization of distress” * 3 “considerations” when considering differential * Learning new language * Mood/anxiety * Cultural considerations/conceptualizations of distress

Answer 228

“DREAS”: * Develop Discrepancy * Roll with Resistance * Express Empathy * Avoid Argumentation * Support Self-Efficacy

Answer 229

Conflict in interpersonal relationships/ interpersonal deficits (ex: conflict with mother, lack of friendships, break-up) Role dispute/ transitions (ex: divorce) Grief and loss/ complicated bereavement (ex: death of grandfather) Role transition (ex: school)

Answer 230

Chaotic/difficult interpersonal relationships --\> Interpersonal effectiveness Emotional lability --\> Emotional regulation Suicidal ideation/ urges to self-harm --\> Distress tolerance

Answer 231

Techniques - **Chain analysis; “walking the middle path”; mindfulness** Dialectics accepting (radically) and changing; using wise mind; motivational interventions (foot in door, door in face, cheerleading, etc)

Answer 232

Psychoeducation Parenting Skills Relaxation **STABILIZATION PHASE** Affect Modulation Cognitive Processing Trauma Narration & Processing **TRAUMA NARRATIVE PHASE** In vivo Mastery Conjoint Child-Parent Sessions **INTEGRATION/CONSOLIDATION PHASE** Enhancing Safety

Answer 233

Acutely suicidal or homicidal Psychotic Intellectually disabled Bipolar mania Actively abusing substances

Answer 234

"DIME" Distress tolerance Interpersonal effectiveness Mindfulness Emotional regulation

Answer 235

depression generalized anxiety disorder substance use disorder

Answer 236

Patients with a demonstrated history of assaultive behavior psychotic patients who pose a potential for violence should not participate in a group

Answer 237

Involve parents – homework, generalization Externalize the anxiety disorder Less “c”, more “B” in cBT More graduated exposures, less “flooding” Address family accommodation Sit/ discuss the physical sensations vs. emotions

Answer 238

Management of SI/ safety Confidentiality (limits) Psychoeducation about the modality Duration and alternatives to this modality For parents: Need to take active role Engagement for at least 4 sessions for assessment/first part

Answer 239

Availability and willing to participate (all members) Dx in family members Ability to respect the framework; accepting that there is familial issue (and not just prob in patient)

Answer 240

Abuse/ DV Active psychosis Active SU (not able to be sober for sessions)

Answer 241

* **Re-establishment of roles** with recovery and reintegration * **Expression of emotions** and sharing of emotional experience within the family * **Psychoeducational** family intervention: * caregiving in chronic illness, skill in family relationships and community living skills * Stress-diathesis model of biologically based disorders * information, coping skills, and social support for family management of chronic illness, stress and stigma reduction * Adolescence is usually the time for **separation-individuation;** this might be difficult in context of disease

Answer 242

**Psychodynamic**: regression during the course of the disease that may conflict with the patient's developmental needs. Explore the role of his symptoms. **Supportive**: need to express potentially traumatic experience and bring reflection on impacts of this period and diagnosis/anticipations p/r to the future. Coping methods. **CBT:** address potential anticipation of recurrence and disease-related avoidance.

Answer 243

Understand nature/object of proceeding Understand possible consequences of proceedings Ability to distinguish possible pleas (guilty vs non-guilty) Ability to communicate with lawyer/ counsel Understand the function/ structure of the court (key personnel, procedures, goals of the Court) Understand and engage in trial process

Answer 244

Spontaneous resolution at rate of 5-10% per year

Answer 245

Provide psychoeducation and reassure Limit water intake/fluids before bedtime toileting before bed behavioural treatment (bell and pad; \>50% treatment success)

Answer 246

Desmopressin (DDAVP) first line with 60-70% response but high rate of relapse after discontinuing treatment Imipramine

Answer 247

Psychological: higher likelihood of aggression, impulsivity, mood and anxiety symptoms Lower academic achievement Greater risk of injury Greater chances of divorce Higher suicide rates

Answer 248

Look at: Dangerousness/**Risk**, **Amenability** to treatment, Developmental **Maturity** Sources: **assessment tools** **collateral** from third party (family, school, juvenile justice staff) **interviews** with the young person **Past personal history** including past assessments and past legal hx

Answer 249

[a] - vulnerable children–general population - suicide rate–youth - serious consideration of suicide - self-rated mental health - anxiety and/or mood disorders [b] - Canadian Community Health Survey - Statistics Canada - Public Use Microdata File

Answer 250

* Screen time for children **younger than 2 years is not recommended.** * For **children 2 to 5 years, limit routine or regular screen time to less than 1 hour** per day. * Ensure that **sedentary screen time is not a routine part of child care** for children younger than 5 years. * Maintain daily **‘screen-free’ times,** especially for family meals and book-sharing. * **Avoid screens for at least 1 hour before bedtime**, given the potential for melatonin-suppressing effects. * Be present and engaged when screens are used and, whenever possible, co-view with children. * Be aware of content and prioritize educational, age-appropriate and interactive programming.

Answer 251

Set the agenda for the committee Lead the meeting Moderate debate/maintain order and decorum Delegate tasks to members Monitor the implementation of agreements and action points from previous meetings

Answer 252

obesity depression social anxiety ADHD/ ODD addiction PCRP

Answer 253

Language barrier SES/ social determinants of health – finances, transportation, education Stigmatization/ marginalization in the cultural community Groups represented in research/ applicability of research results Culturally – sensitive/ competent care

Answer 254

* **In boys (assigned gender), a strong preference for cross-dressing or simulating female attire; or in girls (assigned gender), a strong preference for wearing only typical masculine clothing and a strong resistance to the wearing of typical feminine clothing** * **A strong preference for the toys, games, or activities stereotypically used or engaged in by the other gender** * **A strong preference for playmates of the other gender** * Incongruence between assigned/ birth gender and experienced/ expressed gender * 6months duration of at least 6 of the following criteria: * A strong desire to be the other gender or an insistence that one is the other gender (or some alternative gender different from one’s assigned gender) * A strong preference for cross-gender roles in make-believe play or fantasy plan. * In boys (assigned gender), a strong rejection of typically masculine toys, games and activities and a strong avoidance of rough-and-tumble play; or in girls (assigned gender), a strong rejection of typically feminine toys, games and activities * A strong dislike of one’s sexual anatomy * A strong desire for the primary and/or secondary sex characteristics that match one’s experienced gender

Answer 255

* Should involve a statistically appropriate number of subjects * Risk : benefit ratio must be favorable * Developmentally appropriate explanations * Should not be undertaken primarily for financial or professional advantage * Confidentiality is more strict, but the limitations of confidentiality where there is a child protection issue must be clearly stated * Obligations to make results/ data public

Answer 256

* Intra-individual variables: * Cognitive functioning * developmental level * temperament (high anxiety may lead to avoidance) * capacities for coping * History of illness/medical experiences * Disease-related influences: * Restrictions in physical mobility * chronicity of pain * central nervous system involvement.

Answer 257

Challenges for Parents * Reorganization of intra-family relationships. * Stress of hospitalizations * Associated costs (work absenteeism) * Parental Anxiety * Parental Psychopathology

Answer 258

Severe depression (resistant to multiple meds and therapy, where patient is not eating, drinking or suicidal–at least 2 trial of appropriate meds, unless life at risk) Mania with or without psychotic features Schizophrenia Catatonia NMS Symptoms must be severe, persistent and life-threatening – refusing to eat or drink, suicidal Demonstrate a lack of treatment response – at least two trials of appropriate meds unless waiting for a response will endanger their life

Answer 259

Treated with respect to their own level of emotion and cognitive maturity They need to be told that death is real and irreversible. They need to know that they are blameless. (Not to be blamed) Feelings and concerned should be expressed Questions should be invited and answered with simplicity, candor and clarity. They need ritual to commemorate their loved ones Attending the funeral and participation in mourning may be beneficial first step

Answer 260

Struggle with stage : identity vs. role confusion – desire to be accepted by peers and belong. This can have a strong influence on their health and they can be concerned about fitting in. Fears about medication and their appearance. May also want to be independent and push limits when it comes to diabetes medication ?Eating disorder

Answer 261

Dorsolateral PFC still maturing (more impulsive, more unplanned behaviour / behavioural disinhibition, more sensation seeking) The reward system of brain (nucleus accumbens) already matured -→ more risk-taking

Answer 262

SNRIs – no evidence. Mood Stabilizers - no evidence. Buproprion - not recommended for use in eating disorders, due to the elevated risks of seizures in this population.

Answer 263

**CANMAT - first line treatment of Mania is Lithium and Risperidone ( Level 1 )** **Classic Euphoric Grandiose Mania** **Few prior episodes** **Mania-depression-euthymia course** **Family history BAD or Li response** **Lithium is the only mood stabilizer HEALTH CANADA approved for treatment of BAD in children 12 years or older ( manic episode )** Lithium is efficient in the management of aggression behaviour disorder. It covers two phases of treatment ( acute and maintenance )

Answer 264

Non-obese Manic adolescent with ADHD - consider Risperdone ( CANMAT) Patient who is not going to adhere or follow instructions about regular diet, water and over the counter medication might be very susceptible for lithium toxicity The Treatment of Early Age Mania (TEAM) study : showed that Risperidone was superior than Valproate or Lithium Patient with renal impairment or cardiac abnormalities.

Answer 265

First line : lithium, Risperdone, Quetiapine, Asenapine, Aripiprazole Second line : Olanzapine , Zipradizone , Quetapine (adjunctive therapy ) Third line treatment : valproic acid

Answer 266

3/12 of “WRENCHES MPG” * Waxy flexibility * Rigidity * Echopraxia * Negativism * Cataplexy * High level of motor activity (agitation) * Echolalia * Stupor, Stereotypy * Mutism, Mannerism * Posturing * Grimacing

Answer 267

* Specific Learning Disorder, With Impairment in Reading * Can include * Word reading accuracy * Reading rate or fluency * Reading comprehension * Alternatively, can label certain pattern of reading disabilities “dyslexia" * Dyslexia Features * **Decoding** (Difficulty reading due to problems identifying speech sounds and learning how they relate to letters/ words) * **Slower** pace, less fluid * **Inversion** of syllables * Difficulty with word **recognition** * Poor **Spelling**

Answer 268

LDs (writing, math) **ADHD** **ODD** **CD** DCD ASD anxiety/ depression

Answer 269

Persistent deficits in **communication** and social interactions (3/3) 1. Deficits in socio-emotional **reciprocity** 2. Deficits in **non-verbal** 3. Deficits in establishing, maintaining and understanding **relationships** Restricted patterns of behaviour/ interests/ activities **RRBIS** (2/4) 1. Stereotyped or **repetitive** motor movements, use of objects or speech 2. Insistence on **sameness**, inflexible adherence to routine, ritualized patterns of verbal or nonverbal behavior 3. Highly restricted, **fixated interests** that are abnormal in intensity or focus 4. **Hyper** or **hyp**o-reactivity Present in early developmental period and impair function Clinically Significant Impairment Not better explained by ID/GDD _Severity:_ * “Requiring very substantial support” * “Requiring substantial support” * “Requiring support”

Answer 270

* Developmental, medical, family, social history * Info from school, child care, community * Audiology, vision assessment * Direct Clinical Observation * +/- ASD Diagnostic tool (eg. ADOS) * DSM-5 Diagnostic Criteria

Answer 271

* _Fragile X_ – X-linked d/o, FMR1 gene is turn off by a **large expansions (n \>200) of a (CGG) (n) trinucleotide repeat in the promoter region of the FMR1 gene.** * _Tuberous Sclerosis_ – autosomal dominant; mutation in either TSC1 or TSC2 gene; most often spontaneous mutation * _PKU_ – autosomal recessive; mutation on chromosome 12 (between q22-24) leading to deactivation of the enzyme that converts phenylalanine to tyrosine.

Answer 272

_Fragile X_ – X-linked d/o, FMR1 gene is turn off by a **large expansions (n \>200) of a (CGG) (n) trinucleotide repeat in the promoter region of the FMR1 gene.**

Answer 273

_Tuberous Sclerosis_ – autosomal dominant; mutation in either TSC1 or TSC2 gene; most often spontaneous mutation

Answer 274

_PKU_ – autosomal recessive; mutation on chromosome 12 (between q22-24) leading to deactivation of the enzyme that converts phenylalanine to tyrosine.

Answer 275

* _Down Syndrome_ – Recombination/ translocation mutation called Trisomy 21, extra full or partial copy of chromosome 21

Answer 276

* _Prader- Willi_ - loss of active genes in a specific part of chromosome 15, the 15q11-q13 region; occurs when the paternal copy is partly or entirely missing.

Answer 277

* _Angelman Syndrome_ – 15 q12 deletion, maternal (the copy from father is silent)

Answer 278

* Prenatal ETOH exposure induces the following abnormalities in developing heart * Atrial and ventricular abnormalities * Valve formation abnormalities * Specific Defects associated with prenatal ETOH exposure * Atrioventricular valve defects * Ventricular septal defects * Enlargement of left ventricle * Increased risk of cardiac disease in adulthood

Answer 279

* Renal - hypoplastic kidney, horseshoe * Skeletal - contractures, pectus excavatum * Ocular - strabismus, nerve hypoplasia * Auditory - conductive and sensorineural hearing loss * Endocrine - IUGR, FTT * Neurological - small head size, coordination difficulties, developmental delays, LDs

Answer 280

**School** – increased (EA) supports, IEP, specialized classrooms, school psychologist evaluation, Applied Behavioural Analysis for school setting **Extracurricular** – sports/ camps, adapted jobs **Family** – respite, environmental modifications, caregiver training, disability tax credit (DTC- federal)

Answer 281

**Enlarged Brain Volume of frontal and temporal lobes** **Bigger amygdala** **Corpus collosum reduced in size** **Increased cortical thickness and atypicalities in gyration patterns** Bigger head/ brain size (macrocephaly) Bigger ventricles (ventriculomegaly) Corpus collosum reduced in size \*No diagnostic findings

Answer 282

**Thin upper lip (4 or 5 on Univ of Washington scale)** **Smooth philtrum (4 or 5 on Univ of Washington scale)** **Short palpebral fissures (\<3^rd Percentile)** Short epicanthal folds Short, up-turned nose Flat midface Microcephaly “rail road track” ears Short interpupilary discharge (eyes closer together) Under-developed jaw Pectus excavatum Septal heart defects Renal problems Auditory and vision problems Deformities in limbs and fingers

Answer 283

CMAJ Guidelines: With facial features * 3 facial features * Confirmed or unknown in utero ROH exposure * Impairment in 3 or more neurodev domains OR microcephaly if infant Without facial features * Impairment in 3 or more neurodev domains * AND confirmed in utero exposure to alcohol at recognized dose (more than 13 drinks per month, more than 2 drinks per setting)

Answer 284

IUGR/ low birth weight, small head size, shorter than average + see other physical markers (desribed elsewhere) Poor coordination, hyperactivity, inattention, poor memory, LDs, speech and language delays, vision and hearing problems, poor executive and adaptive functioning skills, difficulty with emotional regulation.

Answer 285

University of Washington Lip-Philtrum Guide

Answer 286

15q11 - Absence of expression of paternally active genes in a region of long arm of Chromosome 15 (15q11.2-13) Physical: **hypotonia**; FTT/ **obesit**y; **small** hands and feet; **almond-shaped** eyes; fair hair and light skin; f**lat face**; **narrowing of the head at the temples**; prominent **forehead**; turned-down mouth; thin upper lip; **scoliosis (**37%); **seizures** (25%); hypothyroidism (30%); **short stature**; under-developed genitals Psycho-emotional: **hyperphagia**; **hoarding**; **impulsive**; borderline to moderate **ID**; emotional **lability and tantrums**; excessive daytime sleepiness; skin picking/ excoriation (85%) ; **obsessions/ compulsion**s; anxiety; aggression Strengths – reading, visual-spatial.

Answer 287

Social isolation Awareness of deficits (level 1) Sudden loss; stress at home/ school Low self-esteem ACEs/ abuse FHx of depression

Answer 288

Comorbid disorders - anxiety, depression, etc... High functioning ASD ACEs (abuse/ trauma/ bullying) Big transitions/ changes in routine

Answer 289

Comorbidities: Schizophrenia Intellectual disability Specific learning disorder Major Depression Anxiety Disorder ADHD Preserved Executive Function: **Verbal IQ** (receptive language better than expressive and verbal memory better than visuospatial memory)

Answer 290

Fragile X PKU Tuberous Sclerosis

Answer 291

a) Specific learning disorder, in written expression b) **WIAT (Weshcler Individual Achievement Test** **Test of written language (TOWL)** WISC (Weschler Intelligence Scale for Children)

Answer 292

Concurrent LDs, ADHD, Language/ communication disorders, Developmental Coordination Disorder ASD, anxiety/ depression

Answer 293

Cognitive and behavioural difficulties (DSM-5 Condition for Further Study): 1. Impaired executive functioning 2. Attention deficit 3. Impaired impulse control 4. Impaired adaptive/daily living skills 5. Impaired affect regulation Other: IQ\<70, Impaired learning, impaired memory, impaired visual-spatial reasoning, communication deficit, impaired social interaction, impaired motor skills

Answer 294

Investigations: 1. Physical exam for sentinel facial features: Palpebral fissure length \>2 SDs below mean; Philtrum rated 4/5, Upper lip rated 4/5 on University of Washington Lip-Philtrum Guide 2. Psychoeducational testing Other: EEG if seizures, PT/OT assessment

Answer 295

Word reading accuracy Reading rate/fluency Reading comprehension

Answer 296

* **B criteria** – RRBIs, 2/4: 1. Stereotyped or repetitive motor movements, 2. Insistence on sameness, inflexible adherence to routines, or ritualized patterns of verbal or nonverbal behavior 3. Highly restricted, fixated interests 4. Hyper- or hyporeactivity to sensory input

Answer 297

Florid **delusions and hallucinations** rarely seen in ASD **Temporal evolution**/onset of symptoms (ASD deficits in social communication within first 3 years of life, onset of childhood schizophrenia typically after age 7) ASD more **pronounced repetitive behaviours** and stereotyped language

Answer 298

ADHD ASD Seizures (does this count?) Anxiety Mood disorders (depression, PDD)

Answer 299

Treatment with stimulants if ADHD is present (80% comorbidity in males) Risperidone, Aripiprazole

Answer 300

physical health review of systems/rule out GMC= pain, constipation, infection mental health review of systems/rule out other MH diagnosis= mood, anxiety, sensory sensitivities, hx of aggression, sleep triggers= being denied something child wants; transitions; trauma; new intervention substance use

Answer 301

FDA-approved for irritability in ASD: **Risperidone** (5-16 years) **Aripiprazole** (6-17 years)

Answer 302

**Neurodevelopmental disorders** Attention-deficit hyperactivity disorder Global developmental delay or intellectual disability Language or learning disorder Social (pragmatic) communication disorder\* Stereotypic movement disorder Tourette’s disorder or a tic disorder **Mental/Behavioural disorders** Anxiety disorders Conduct disorder Depressive disorders Disruptive mood dysregulation disorder Obsessive compulsive disorder Oppositional defiant disorder Reactive attachment disorder Schizophrenia Selective mutism **Genetic conditions** Fragile X syndrome Rett syndrome Other genetic variants (e.g., 16p11 deletion) and genetic syndromes\*\* **Neurological and other medical conditions** Cerebral palsy Epilepsy Landau-Kleffner syndrome **Mitochondrial disorders** Neonatal encephalopathy

Answer 303

Prenatal etoh history 3 sentinel facial fts Evidence of deificts in 3 neurocog domains +/- microcephaly

Answer 304

Atypicals – Risperidone Adrenergic Agents – clondiidne Amphetamine-based stimulants – lisdexamphetamine

Answer 305

1. Emotion recognition training 2. Greater use of visual information 3. More cognitively concrete and structured approach; simplify cognitive activities 4. Involve parents to support implementation of intervention 5. Offer regular breaks to maintain attention 6. Use Child’s interests in therapy

Answer 306

physical health **review of systems**/rule out GMC= pain, constipation, infection mental health review of systems/r**ule out other MH diagnosis**= mood, anxiety, sensory sensitivities, hx of aggression, sleep **triggers**= being denied something child wants; transitions; trauma; new intervention **substance use**

Answer 307

FDA-approved for irritability in ASD: - Risperidone (5-16 years) - Aripiprazole (6-17 years)

Answer 308

Socio-emotional communication challenges Blunted affect and alexythmimia Alteration of theory of mind and alteration of interpretations and use of non-verbal language and facial expressions.

Answer 309

ADHD ASD Seizures (does this count?) Anxiety Mood disorders (depression, PDD)

Answer 310

Treatment with stimulants if ADHD is present (80% comorbidity in males) Risperidone, Aripiprazole

Answer 311

Lithium, Risperidone, Quetiapine

Answer 312

Lurasidone Lithium Lamotrigine

Answer 313

RLS (or PLMD theoretically) OSA (+limb jerks associated with OSA) ADHD Delayed sleep-wake phase disorder Hypnagogic foot tremor Anxiety/MDD

Answer 314

* Polysomnography * Blood work - ferritin, iron, Mg, thyroid, renal/ liver indicators, CBC

Answer 315

ADHD ODD anxiety (separation anxiety, specific phobia, generalized anxiety) ID/ASD

Answer 316

**Bowel Retraining** * **Disimpaction** (for children with a large rectal stool mass or fecal incontinence) * Prolonged **laxative** treatment and behavioral therapy to achieve regular evacuation and avoid recurrent constipation * **Dietary** changes (primarily increasing fiber and fluid content) to maintain soft stools * Gradual tapering and **withdrawal of laxatives** as tolerated **Behaviour Modification** * Toilet **Sitting** * **Rewards**

Answer 317

Educational/ skill building Empowerment Sense of belonging Universality; support network Self-care/ restorative Motivating for Parents Hope

Answer 318

Temperamental Risk (DSM-5): behavioural inhibition negative affectivity neuroticism harm avoidance anxiety sensitivity (disposition to believe that symptoms of anxiety are harmful) shyness

Answer 319

Infants: loud noises, being startled, strangers Preschool age: imaginary creatures, darkness, separation School age: injury, natural events (e.g., storms) Adolescent: school performance, social competence, health issues

Answer 320

**Confirm** diagnosis + comprehensive psychiatric assessment + **risk** assessment (pt and **collateral**) Treatment has three phases: (psychoed, supprto for pt, fam, school) **acute** **continuation** **maintenance** **Mild** MDE -→ **Supportive** clinical care may reduce symptoms (psychoed, restoration of hope, empathetic listening, lifestyle advice, coping skills, sleep hygiene, exercise) **Psychotherapy is first line** for mild-mod MDD (either **CBT or IPT**) **Mod-severe MDD** /not responded to psychotherapy/ pt pref-→ **Meds** (fluoxetine, escitalopram, sertraline, venlafaxine) If med started, **assess weekly x4 weeks**, then **every 2 weeks for one month**, **then after 12 weeks** to assess for side effects **Start on low-end** of therapeutic dose range and consider **dose adjustments q 4** weeks **Treat for 6-12 month**s if first episode and taper slowly during stress-free time When using medications, **combine with psychotherapy**

Answer 321

Canadian practice guidelines for the treatment of children and adolescents with eating disorders (2020) 1. Family-based treatment (FBT) (strong recommendation) 2. CBT for AN (weak recommendation) 3. Adolescent Focused Psychotherapy for AN (weak recommendation)

Answer 322

Olanzapine But there is little actual research evidence for weight gain in AN: - Only DBPCT (Bissada, 2008) was negative - Three case-control studies “Those in the medication group demonstrated a significantly higher rate of weight gain in the first 4 weeks, although approximately one third of participants discontinued olanzapine early due to side effects” - Two positive case series

Answer 323

Bupropion, seizure risk

Answer 324

**Lithium is not metabolized**, it is rapidly and completely **absorbed**, with a bioavailability of 80-100% Half-life in children is 27 hours, adults 18-36 hours **Excreted in the urine** (**unchanged** drug) Clearance: 80% of filtered lithium is reabsorbed in the proximal convoluted tubules in pediatric patients

Answer 325

**Half-life shorter** **Clearance faster** than in adults

Answer 326

Family History of Response to Lithium Family History of Bipolar Disorder Classic Symptomatology of BP (eg, euphoric mania) Later age of disease onset Fewer hospitalizations preceding treatment

Answer 327

Chronic Clinical Course Rapid cycling

Answer 328

Before an adolescent is considered for ECT, must meet 3 criteria: **Diagnosis** Severe, persistent major depression or mania with or without psychotic features, schizoaffective disorder, or, less often, schizophrenia. Or catatonia and NMS **Severity of symptoms** Symptoms must be severe, persistent, and significantly disabling. Eg. refusal to eat or drink, severe suicidality, uncontrollable mania, and florid psychosis **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 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) w**aiting for a response** to a psychopharmacological treatment **may endanger** the life of the adolescent

Answer 329

Impairment of memory and new learning Tardive seizures Prolonged seizures Risks associated with general anesthesia Adults, fatality rate is 0.2/10,000 treatments, adolescents not believed to be at increased risks Headaches, nausea, vomiting, muscle aches, confusion, agitation

Answer 330

Impairment of memory and new learning Tardive seizures Prolonged seizures Risks associated with general anesthesia Adults, fatality rate is 0.2/10,000 treatments, adolescents not believed to be at increased risks Headaches, nausea, vomiting, muscle aches, confusion, agitation

Answer 331

Impairment of memory and new learning Tardive seizures Prolonged seizures Risks associated with general anesthesia Adults, fatality rate is 0.2/10,000 treatments, adolescents not believed to be at increased risks Headaches, nausea, vomiting, muscle aches, confusion, agitation

Answer 332

Impairment of memory and new learning Tardive seizures Prolonged seizures Risks associated with general anesthesia Adults, fatality rate is 0.2/10,000 treatments, adolescents not believed to be at increased risks Headaches, nausea, vomiting, muscle aches, confusion, agitation

Answer 333

Comorbid MDD Younger age of onset Duration of symptoms Other comorbid anxiety disorders No longer attending school/school phobic

Answer 334

**Tourette Syndrome & Tic** Disorder (CADDRA) Third Line treatment of **ADHD** (along with Bupropion, Imimpramine, Modafinil) Others with limited data to support: **PTSD** **Insomnia,** with neurodevelopmental disorder as alternate therapy

Answer 335

**alpha-2-adrenergic agonists** **Stimulates alpha-2 adrenoceptors** in the **brain stem**, thus activating an inhibitory neuron, resulting in **reduced sympathetic outflow from the CNS**, producing a **decrease in peripheral resistance, renal vascular resistance, heart rate, and blood pressure** In ADHD, unknown, proposed that **postsynaptic alpha-2 agonist stimulation regulates subcortical activity** in the prefrontal cortex

Answer 336

Somnolence and sedation BP, risk of hypotension Bradycardia, syncope Elevated BP and HR upon abrupt discontinuation – should always be tapered down progressively if discontinuing QTc interval (to be monitored if underlying conditions or other medication increase the risk of prolonged QTc interval)

Answer 337

**Irritability** **Physical Aggression** Severe tantrum behaviour Self-Injury “Quickly changing moods” (UpToDate) **Treatment of repetitive/stereotypic behaviours** **Psychosis/bipolar mania/tics**

Answer 338

**Adverse childhood experiences** **Bullying** **“mental disorders”:** Anxiety, depression, personality disorders **female gender** (maybe less so?) **physical symptoms:** disabilities and sleep problems **low health literacy** **problem behaviours** alcohol/substance use, smoking, problematic mobile phone use, having run away from home, suicide attempt, internet/mobile phone abuse, intentional misuse of prescription medications, avoidance, opioid misuse, sedative misuse, and gaming disorder

Answer 339

Physical abuse Sexual abuse Emotional abuse Physical neglect Emotional neglect Mental illness Divorce Substance abuse Violence against your mother Mental illness Having a relative who has been sent to jail or prison

Answer 340

Female gender previous trauma exposure multi- ple traumas greater exposure to the index trauma presence of a preexisting psychiatric disorder (particularly an anxiety disorder) parental psychopathology lower socioeconomic status lower education and intelligence childhood adversity cultural characteristics lack of social support Peritrauma factors - severity of the trauma, degree of perceived threat to life, personal injury, degree of interpersonal violence Temperamental traits - inappropriate coping strategies and negative appraisals

Answer 341

parental support lower levels of parental PTSD resolution of other parental trauma-related symptoms

Answer 342

**pre-pregnancy**= f**amily/parental history** of **ADHD**; family/parental history of **conduct disorder** **pregnancy**= **maternal stress**; **exposure** to tobacco/alcohol/drugs/toxins; l**ow birth weight**; **prematurity** **delivery**= neonatal **anoxia**/brain injury; **exposure** to lead/toxins **infancy/childhood**= family **conflict**; **inconsistent** parenting; early **deprivation**

Answer 343

Attention Deficit Hyperactivity Disorder (ADHD) Intellectual Disability Learning Disorders Oppositional Defiant Disorder depressive and anxiety disorders substance use suicidality

Answer 344

**Social skills school based programs** \*\*\*\* **Parent training for ODD** School-based prevention programs offer an efficient mechanism for delivering prevention interventions Clinicians who serve as consultants to schools need to be familiar with these programs. A detailed discussion of this complex literature is contained in the recent summaries by

Answer 345

**Harsh** **Inconsistent** **Neglectful** …child-rearing practices are common in families of children and adolescents with oppositional defiant disorder

Answer 346

Angry/irritable mood Argumentative/Defiant behaviour Vindictiveness

Answer 347

* **Anxiety and mood problems** * **Risk for developing conduct disorders** * **Increased risk of suicide attempts**

Answer 348

**Social and Communication impairments** are seen in ASD and not anxiety disorders **Developed social insight in anxiety disorders** is not seen in ASD **RRBIs seen in ASD** not present in Social Anxiety Disorder **Early Development not affected in anxiety** disorders compared to ASD

Answer 349

Children with **RAD have deficits in attachment and social responsiveness** but these improve substantially if adequate caretaking is provided whereas **in ASD they do not improve t**o the same degree **No selective impairments in symbolic representation** (e.g., pretend play and language) out of proportion with cognitive level **in RAD** compared to ASD **Restricted interests and preoccupations seen in ASD** are not found in RAD

Answer 350

a) Delirium secondary to infectious process Neuroleptic Malignant Syndrome (Fluoroquinolones e.g., Ciprofloxacin inhibit CYP1A2, can increase levels) Encephalitis ?Substance induced psychosis b) Physical exam + neuro exam, vitals CBC, lytes, glucose, extended lytes, CK, Cr and Urea, Liver Enzymes, Fe, blood cultures Urine myoglobin Referral to Pediatrics or send to ED ?Imaging ?Lumbar puncture Urinalysis CXR UDS

Answer 351

Transient Disorientation post session Subjective and objective CI Retrograde amnesia Anterograde amnesia Mild, ST impairment in memory and other cog domains

Answer 352

Right unilateral electrode placement (vs bilateral) Bifrontal electrode placement vs bitemporal Ultra brieff pulse width vs brief pulse width Decrease electrical stimulus Reduced frequency and # of sessions Reduce anaesthetic agent DC meds that with known side effects prior to ECT esp Lithium

Answer 353

Dystonia/EPS Encephalitis Head Trauma CVA Delirium Systemic Infection Malignant catatonia Malignant Hyperthermia Seizure – status epilepticus Alcohol/sedative withdrawal Serotonin syndrome

Answer 354

- Fever (\>38) - Altered mental status - Autonomic instability (tachycardia and HTN) Also, dysrhythmias, diaphoresis, sialorhea, dysarthria, dysphagia, tremor, dystonia

Answer 355

CBC, lytes, Cr, LFTs, Lactate, ext lytes, ABG or VBG Urinalysis, urine drug screen Blood Culture, LP CT/MRI, EEG

Answer 356

CBC - leukocytosis CK - increased, \>1000 LFTs - mild increase Lactate - mild increase Cr - increased if renal failure secondary to rhabdo Lytes - increased/decreased Na, decreased Ca, decreasged Mg ABg - acidosis Imaging - usually normal, except in prolonged acidosis/hyperthermia, cerebral edema LP - normal, maybe slight increase in protein EEG - to rule out non-convulsive status, generalized slowing

Answer 357

- Antipsychotic use = major risk factor Previous NMS High potency typicals - initiated in last 2 weeks - dose increased quickly - if switch was made from another agent if IM/depot Aggravating factors - Lithium Como substance use neuro dx recent med illness dehydration (or early complication)

Answer 358

1. Stop the causative agent – discontinue all antipsychotics. 2. Discontinue other potential contributors, including lithium, anticholinergics, SSRIs, and MAOIs. 3. Treat agitation with benzodiazepines as needed. 4. Aggressive supportive care: a. ICU setting – including monitors, ventilation and antiarrhythmics prn. b. Aggressive IV hydration is necessary. c. Urine alkalization may be considered if CK is very high to help eliminate myoglobin to prevent renal failure. d. Cooling blankets for high fevers are necessary. 5. Possible treatments are few, and evidence is limited: a. Dantrolene IV to relax skeletal muscles has been used with success in some cases. b. Bromocriptine (a dopamine agonist) may restore lost dopamine tone. Amantadine is another alternative agent acting in this manner. c. ECT has been met with some success clinically in severe cases, but risks in this sick population is very high. Arrhythmias and status epilepticus have been reported.

Answer 359

VTE Dehydration Electrolyte Imbalance Acidosis Rhabdomyolisis Renal failure 2 to rhabdo cardiac arrhythmias MI 2 to hyperthermia/lyte DIC Liver failure sepsis seizures

Answer 360

- Most resolve within 2 weeks wo sequelae if proper supp care given and no prolonged hyperthermia or hypoxia - maybe takes longer if depot APs given - 5-20% mortality rate (usually highest with increased myoglobin, acute renal failure, preesxisting organic brain disease, substance abuse)

Answer 361

- Yes - NMS may occur, idiosyncratic rxn, 10-90% - Risks for recurrence first few weeks after NMS use of high potency IM/Depot Concomitant li Dehydration

Answer 362

Endocrine/GI issues - Addisions -Hyperthyroid - Malabsorption - IBD - Celiac - Some cancers (lymphoma, b-symptoms)

Answer 363

Orthostatic vitals CBC Electrolytes Magnesium, Calcium, Phosphorus Creatinine (+/- Urea) Liver enzymes, including Alkaline phosphatase Ferritin Folate, B12 levels TSH EKG Urine pregnancy test Urinalysis Bone Density scan (DEXA) For DM, also add: Capillary blood glucose monitoring HbA1c Serum pH and urine for ketones (if DKA suspected)

Answer 364

* Neuro: cognitive decline (with possible grey/white matter changes), seizures, decreased LOC, myopathies, smooth muscle wasting * Dental: generally in cases where vomiting is used in purging (so not this patient) * Skin: lanugo hair, xerosis/dry skin, edema, nail changes, cold intolerance, + many, many more * Respiratory: decreased lung function secondary to malnutrition/muscle wasting * CVS: bradycardia, prolonged QT, orthostatic hypotension, dysrhythmias, anaemia * GI: salivary gland enlargement/changes (again in cases with vomiting, so not likely in this patient), decreased esophageal/gastric/bowel motility (often leading to postprandial bloating), constipation or loose stools, poor digestion * Endocrine: amenorrhea/infertility, hypothermia/cold intolerance, hypoglycaemia, decreased libido, + many, many more * Renal: decreased urine volume, nocturia, urinary frequency * Bones: osteopaenia, osteoporosis (generally only AN)

Answer 365

Transient Disorientation post session Subjective and objective CI Retrograde amnesia Anterograde amnesia Mild, ST impairment in memory and other cog domains

Answer 366

Right unilateral electrode placement (vs bilateral) Bifrontal electrode placement vs bitemporal Ultra brieff pulse width vs brief pulse width Decrease electrical stimulus Reduced frequency and # of sessions Reduce anaesthetic agent DC meds that with known side effects prior to ECT esp Lithium

Answer 367

Dystonia/EPS Encephalitis Head Trauma CVA Delirium Systemic Infection Malignant catatonia Malignant Hyperthermia Seizure – status epilepticus Alcohol/sedative withdrawal Serotonin syndrome

Answer 368

- Fever (\>38) - Altered mental status - Autonomic instability (tachycardia and HTN) Also, dysrhythmias, diaphoresis, sialorhea, dysarthria, dysphagia, tremor, dystonia

Answer 369

CBC, lytes, Cr, LFTs, Lactate, ext lytes, ABG or VBG Urinalysis, urine drug screen Blood Culture, LP CT/MRI, EEG

Answer 370

CBC - leukocytosis CK - increased, \>1000 LFTs - mild increase Lactate - mild increase Cr - increased if renal failure secondary to rhabdo Lytes - increased/decreased Na, decreased Ca, decreasged Mg ABg - acidosis Imaging - usually normal, except in prolonged acidosis/hyperthermia, cerebral edema LP - normal, maybe slight increase in protein EEG - to rule out non-convulsive status, generalized slowing

Answer 371

- Antipsychotic use = major risk factor Previous NMS High potency typicals - initiated in last 2 weeks - dose increased quickly - if switch was made from another agent if IM/depot Aggravating factors - Lithium Como substance use neuro dx recent med illness dehydration (or early complication)

Answer 372

1. Stop the causative agent – discontinue all antipsychotics. 2. Discontinue other potential contributors, including lithium, anticholinergics, SSRIs, and MAOIs. 3. Treat agitation with benzodiazepines as needed. 4. Aggressive supportive care: a. ICU setting – including monitors, ventilation and antiarrhythmics prn. b. Aggressive IV hydration is necessary. c. Urine alkalization may be considered if CK is very high to help eliminate myoglobin to prevent renal failure. d. Cooling blankets for high fevers are necessary. 5. Possible treatments are few, and evidence is limited: a. Dantrolene IV to relax skeletal muscles has been used with success in some cases. b. Bromocriptine (a dopamine agonist) may restore lost dopamine tone. Amantadine is another alternative agent acting in this manner. c. ECT has been met with some success clinically in severe cases, but risks in this sick population is very high. Arrhythmias and status epilepticus have been reported.

Answer 373

VTE Dehydration Electrolyte Imbalance Acidosis Rhabdomyolisis Renal failure 2 to rhabdo cardiac arrhythmias MI 2 to hyperthermia/lyte DIC Liver failure sepsis seizures

Answer 374

- Most resolve within 2 weeks wo sequelae if proper supp care given and no prolonged hyperthermia or hypoxia - maybe takes longer if depot APs given - 5-20% mortality rate (usually highest with increased myoglobin, acute renal failure, preesxisting organic brain disease, substance abuse)

Answer 375

- Yes - NMS may occur, idiosyncratic rxn, 10-90% - Risks for recurrence first few weeks after NMS use of high potency IM/Depot Concomitant li Dehydration

Answer 376

Endocrine/GI issues - Addisions -Hyperthyroid - Malabsorption - IBD - Celiac - Some cancers (lymphoma, b-symptoms)

Answer 377

Orthostatic vitals CBC Electrolytes Magnesium, Calcium, Phosphorus Creatinine (+/- Urea) Liver enzymes, including Alkaline phosphatase Ferritin Folate, B12 levels TSH EKG Urine pregnancy test Urinalysis Bone Density scan (DEXA) For DM, also add: Capillary blood glucose monitoring HbA1c Serum pH and urine for ketones (if DKA suspected)

Answer 378

* Neuro: cognitive decline (with possible grey/white matter changes), seizures, decreased LOC, myopathies, smooth muscle wasting * Dental: generally in cases where vomiting is used in purging (so not this patient) * Skin: lanugo hair, xerosis/dry skin, edema, nail changes, cold intolerance, + many, many more * Respiratory: decreased lung function secondary to malnutrition/muscle wasting * CVS: bradycardia, prolonged QT, orthostatic hypotension, dysrhythmias, anaemia * GI: salivary gland enlargement/changes (again in cases with vomiting, so not likely in this patient), decreased esophageal/gastric/bowel motility (often leading to postprandial bloating), constipation or loose stools, poor digestion * Endocrine: amenorrhea/infertility, hypothermia/cold intolerance, hypoglycaemia, decreased libido, + many, many more * Renal: decreased urine volume, nocturia, urinary frequency * Bones: osteopaenia, osteoporosis (generally only AN)

Answer 379

• Recruitment is of patients seeking treatment (as opposed to volunteers responding to advertisements) • Enrollment is high (as opposed to most potential subjects screened out or not consenting) • Sample size is adequate (minimum 30 – 50 subjects per arm) • Exclusion criteria are not overly restrictive (e.g. not excluding people with substance use, suicidal ideation, etc.) • Intervention is something that can actually be done in real life (as opposed one that is so specialized or resource intensive that it cannot readily be undertaken in the local setting) • Outcome is meaningful to clinicians and patients • Harms are measured (e.g. side effects, discontinuation of treatment, worsened suicidal ideation, changes in weight, etc.) • Duration of treatment is long enough to mimic actual practice and to observe potential adverse events • Costs are measured

Answer 380

1. Treat underlying cause (eg. iron deficiency anemia) or DC causative agent 2. Non pharm - decrease ETOH, nicotine and caffeine; hot baths, hot or cold compresses, massage, sleep hygiene 3. Dopamine-agonists (Pramipexole, Ropinarole, then Levodopa) 4. Anticonvuslants (Gabapentin and pregabalin) 5. Benzodiazepenes 6. Low dose oxycodone

Answer 381

Chronotherapy (phase delay) Melatonin early PM Bright light early AM

Answer 382

\>2 years (\>1yr in children) - * numerous periods with hypomanic symptoms **that do not meet** criteria for a hypomanic episode AND * numerous periods with depressive symptoms **that do not meet** criteria for a major depressive episode. * Symptomatic at least half the time * Criteria for a major depressive, manic, or hypomanic episode **have never been met**

Answer 383

* Flu-like symptoms (lethargy, fatigue, headache, achiness, sweating) * Insomnia (with vivid dreams or nightmares) * Nausea (sometimes vomiting) * Imbalance (dizziness, vertigo, light-headedness) * Sensory disturbances (“burning,” “tingling,” “electric-like” or “shock-like” sensations) * Hyperarousal (anxiety, irritability, agitation, aggression, mania, jerkiness)

Answer 384

Hypomanic episode only needs to be 4 days, manic at least a week (or hosp) Hypomanic = marked change in functioning, but NOT functioanl impairment Both need 3/7 DIGFAST criteria

Answer 385

* Symptoms * Mood reactivity brightening in response to circumstances * Overeating * Oversleeping * Leaden Paralysis * A long-standing pattern of interpersonal rejection sensitivity * Assoc with * Younger age of onset * more severe psychomotor slowing * COMO panic disorder, SUD, and somatization

Answer 386

Classic depression: severe anhedonia, early morning awakening, weight loss, and profound feelings of guilt

Answer 387

Association of bed with state of arousal

Answer 388

CBT for Insomnia 3 stages 1. Sleep hygiene and education, stimulus control, sleep restructuring 2. Cognitive therapy, relaxation training 3. Medication taper

Answer 389

Use for short-term, trasnient insonia eg when in hospital Use lwoest effective dose, intermittent dosing, gradually taper off Not indicated for chronic insomnia EG. Temazepam, zopiclone, zolpidem, doxepin, orexin and melatonin antagonists

Answer 390

CPAP Nasal surgery Oral devices Don't sleep supine DO NOT use narcotics, benzos, opioids

Answer 391

Chronotherapy (phase delay) Melatonin early PM Bright light early AM

Answer 392

ANK3 - Voltage gated sodium channels CACNA1C on 12p13 - L type Ca Channels

Answer 393

1. Start opioid agonist treatment (OAT) with buprenorphine/naloxone whenver feasible 2. For poor responders to above, consdier transition to methadone 3. If good response to methadone, consider transitioning to buprenorphine naloxone

Answer 394

* Pt needs to be in at least moderate withdrawal to start (COWS \>12) * 12-24 hours of abstinence since last opiod dose * Begin at 2-4mg, increase by up to 8mg/day * Max 24mg/day

Answer 395

Precipitated withdrawal Resp depression/sedation Headache, fatiguw, occasional sexual SE

Answer 396

* Suboxone * Buprenorphone is a partial opiod antagonist at mu receptor * Has a higher affinity for opioid receptor so displaces otehr opioids * But its maximal opioid agonist effect is lower than FULL op-ags (methadone, morphine, heroin) * "Ceiling effect" lowers risk of resp depression, side effects, non-med use * Naloxone os mu opioid receptor antagonist, can block the effect of buprenorphine * Methadone * FULL opiod agonist at mu receptor * increased risk for AEs and OD and death * When used as directed, safe and effective for OUD tx

Answer 397

* QTC Prolongation * Black Box Warning * Addiction, abuse, misuse * Resp depression * 3A4, 2C19,2C9,2D6 inhibitors could icnrease methadone levels --\> resp depression * Serotonin syndrome if with other S-agents

Answer 398

* Euphoria * ↓ appetite * ↑vigilance * ↑ autonomic activity (or possibly ↓) * ↑seizures * ↑psychosis - paranoid delusions * ↑ nausea vomiting * ↑ arrhythmias * ↑ psychomotor behaviour - agitation, stereotyped behaviour eg dyskinesias

Answer 399

* Acute - ↑ serotonin (blocks reuptake, directly releases S) * Chronic - ↓ serotonin levels by depleting stores and inhibiting synthesis of new S

Answer 400

* Acute * serotonin levels by blocking reuptake, directly releasing S * Chronic * ↓ serotonin levels by depleting stores, inhibiting synthesis of new S

Answer 401

* Cocaine * Metabolizes **rapidly** * Effects last 1-2 hours * Withdrawal 1-2 days * Methamphetamine * Metabolizes **Slowly** * Effects can last 10-20 hours * Withdrawal can last several days * Recall meth --\> 1000% ↑ of DA in NA (vs food 150%, sex 200%)

Answer 402

* CBC, lytes, CAMP, albumin, LFTS, Cr, Urea * ECG

Answer 403

* Prn means non-regularly scheduled medication * prn medication requires informed consent (either from patient or SDM) in most situations * Chemical restraint is a category of non-regularly scheduled medication that can be given without informed consent but _only_ in the event of behaviour which is causing a high likelihood of risk of harm coming to the patient or to others. * Chemical restraint orders must be reassessed on a daily basis

Answer 404

* Pros: helps with compliance, ensures a constant delivery of medication, some patients may prefer not to have to deal with pills, health care providers have accurate information about compliance * Cons: delayed release of drug can make dosing challenging and results in a prolonged period of time before the medication takes effect, the long half-life of injectable antipsychotics means that any adverse reactions last longer than with oral medications, many patients may not feel comfortable with the idea of receiving an injection

Answer 405

Criteria for initiation of a CTO: 1. Having an Axis I disorder 2. A history of non-adherence to psychiatric follow-up and/or psychiatric medications 3. A history of at least 2 psychiatric hospitalizations in the last 3 years and/or a psychiatric hospitalization that lasts at least 30 days in the last 3 years 4. A history of improvement in psychiatric symptoms when patient is adherent to psychiatric treatment

Answer 406

Assessment for diagnosis of Intellectual disability: IQ testing and assessment of adaptive functioning using an adaptive behaviour scale Diagnostic Criteria for Intellectual Disability: A. Deficits in intellectual functions, such as reasoning, problem solving, planning, abstract thinking, judgment, academic learning, and learning from experience, confirmed by both clinical assessment and individualized statrdized intelligence testing. B. Deficits in adaptive functioning that result in failure to meet developmental and sociocultural standards for personal independence and social responsibility. Without ongoing support, the adaptive deficits limit functioning in one or more activities of daily life. C. Onset of intellectual and adaptive deficits during the developmental period.

Answer 407

* Non-stimulant medications * Atomoxetine, Guanfacine * Long Acting Stimulants * Vyvanse – pro (inactive) drug that requires first pass metabolism, so it cannot be injected * Other long-active stimulants (ie: Concerta/ OROS)

Answer 408

_SUD Dx:_ At least 2 sx for 12months In this case: missing school and interpersonal problems so 2 sx (likely more in the stem) = mild (2-3sx) _ODD Dx:_ At least 4 sx for 6 months In this case: not following rules so 1sx (likely more in the stem) _CD Dx:_ At least 3 sx for 12 months (with 1 in last 6 months) In this case: missing school _What can parents do:_ * Promote positive social activities * Improve parent-child relationship * Positive reinforcement of abstinence

Answer 409

_What can parents do:_ * Promote positive social activities * Improve parent-child relationship * Positive reinforcement of abstinence

Answer 410

Physical/ medical: • GI symptoms such as abdominal pain, fever, chills, diaphoresis, headaches, tremors Psychological: • Depression, anxiety, irritability/ anger, insomnia, appetite changes, restlessness Withdrawal symptoms commonly occur 24 h to 72 h after last use and persist for 1 to 2 weeks. Sleep disturbance is often reported for up to 1 month.

Answer 411

Intoxication: LSD Phencyclidine (PCP Psylocibin (“mushrooms) Ketamine Dextromethorphan (DMT) (in high doses) Withdrawal: alcohol VH is less common with MDMA and much less common with cocaine \*Serotonin is the major neurotransmitter in the neurochemical pathway of hallucinogens (including LSD, PCP, and Psylocibin) \*DMT and Ketamine are NMDA-receptor antagonists \*Dopamine is released from classical amphetamines (e.g. methamphetamine, methylphenidate) \*Dopamine, NE, and serotoin are implicated in the designer amphetamines (e.g. MDMA) \*Dopamine reuptake is blocked by cocaine

Answer 412

1) Psychoeducation 2) Parent skills training (e.g., treatment entry training and safety training and communication skills training) 3) Re-establish hierarchy and boundaries 4) Use of positive reinforcement and contingency management 5) Engage in pro-social/positive activities (sport, arts, etc) 6) Motivational enhancement A) Community Reinforcement and Family Training B) Multisystemic Therapy (as for conduct disorder/antisocial behaviours) C) Brief Strategic Family Therapy D) Multidimensional Family Therapy E) Functional Family Therapy

Answer 413

1. **(THC) stimulates cannabinoid receptors type-1 (CB1)** throughout the CNS (highest concentrations in amygdala, hippocampus, basal ganglia, anterior cingulate cortex and prefrontal cortex) and CB2 receptors peripherally 2. **CBD has little binding affinity for either CB1 or CB2** receptors, but it is capable of **allosterically binding** and antagonizing them in the presence of THC **(reducing the effect of THC**)

Answer 414

Disorder – persistent, significant distress, impaired function/ development Remember: * **Fear** is seen as a reaction to a specific, observable danger * **Developmentally normal does not cause clinically significant distress, impairment in function** * A**nxiety** is seen as a diffuse, a kind of unfocused, objectless, future-oriented fear * **Normative fears do not typicallly persist beyond specific developmental stage** \* Children at younger ages may have **difficulties in communicating cognition, emotions, and avoidance**, as well as the associated distress and impairments, to the diagnostician because they might lack the cognitive capabilities used to communicate information vital to the application of the diagnostic classification system. Thus, **developmental differences (eg, cognition, language skills, emotional understanding) must be carefully considered when assessing anxiety in young people** to make a diagnostic decision

Answer 415

* Highly complex, polygenic * Susceptible genes within the **serotonergic and catecholaminergic** systems (5HTT, 5HT1A, MAOA) & **BDNF** gene * **Short 5HT allele** – 5HT transporter, **5-HTTLPR** * Associated with lower 5-HTT expression and function, as well as anxiety and negative mood * Stress/early trauma interact with molecular plasticity markers

Answer 416

* None in child and adolescent psychiatry by Health Canada * Fluoxetine is 1st line for anxiety disorders according to guidelines * Sertraline, citalopram, fluvoxamine, clomipramine

Answer 417

* DDx: conversion disorder; factitious d/o; somatic symptoms d/o; PTSD/ dissociation; MDD; Seizure disorder; panic disorder * Additional history: aura, urinary incontinence, post-ictal confusion. Gradual start of pseudo-seizure, pelvic thrusting, head side-to-side, normal reflexes post-ictal, crying/talking/distress per-ictal. No nocturnal sz Waxing and waning Eyes Closed Side to side head movements (\>4) Time (\>3 minutes) Crying out Out of phase limb movements Pelvic thrusting Soft toy

Answer 418

Work-up: physical examination including neurological exam blood work including PL EEG Inconsistency of symptoms on examination - Eg. normal EEG during seizure, active resistance to eye opening during pseudo-seizure. PRL post-ictal

Answer 419

* Selective mutism * Separation anxiety

Answer 420

* Somatic symptoms like headaches and belly aches * Irritability, temper tantrums, crying fits * Oppositional behaviour * Regression (skills, behaviour) * School refusal * Sleep difficulties, nightmares

Answer 421

* **Attachment** * **Modelling** – social learning theory, co-regulation * **Accommodation** * Parenting style/ fit * Positive reinforcement

Answer 422

1. Consider : * **Study plan** * **Calm, quiet environment. Noise-blocking headphones.** Separate space/ room to write the exam. * **Cognitive restructuring** * Tutor * More time to complete the exam. * Body breaks * Desensitization – “worst care scenario” 1. Consider : * **SMART goals** - Specific, Measurable, Achievable, Relevant, and Time-Bound * **Relaxation/ mindfulness** * **Cognitive restructuring/ CBT** * Healthy lifestyle including **sleep hygiene**, diet, recreation

Answer 423

1. **Consistent failure to speak in specific social situations in which there is an expectation for speaking (e.g. - at school) despite speaking in other situations.** 2. The disturbance **interferes** with educational or occupational achievement or with social communication. 3. The duration of the disturbance is at **least 1 month** (cannot be during first month of school). 4. The failure to speak is **not attributable to a lack of knowledge** of, or comfort with, the spoken language required in the social situation. 1. The disturbance is not better explained by a communication disorder (e.g. - [childhood-onset fluency disorder](https://www.psychdb.com/child/communication/childhood-onset-fluency-disorder)) and does not occur exclusively during the course of [autism spectrum disorder](https://www.psychdb.com/child/asd), [schizophrenia](https://www.psychdb.com/psychosis/schizophrenia-scz), or another [psychotic disorder](https://www.psychdb.com/psychosis/home).

Answer 424

**Behavioral therapy**. 2 phases – 1) **Positive/ negative reinforcement**, contingency management, parent management training; 2) **Gradual exposure** (desensitization, social skills training, positive reinforcement) and treat comorbidities.

Answer 425

a) **Nightlight** (because of anxiety/ fear; otherwise for sleep hygiene – cool/ dark room) b) **Comfort/ transition item** (ex: stuffy) c) **Bedtime routine including avoidance of screens/ triggers** d) Relaxation techniques, storytelling/ visualization, positive self-talk e) **Extinction procedure re: parents** f) Do not co-sleep with parents

Answer 426

* Child Factors* * 1. Temperament (behavioural inhibition)* * 2. Stressful or humiliating experience; bullying* * 3. Childhood abuse and adversity* * Parent Factors* * 1. Genetics (first deg relatives 2-6x odds)* * 2. Parenting style (accommodating, harsh punishment, authoritarian)* * 3. Vicarious conditioning (anxiety thru observation)* * \<\>*

Answer 427

* Evidence based treatments:* * 1. Psychological: CBT, Social Effectiveness Therapy* * 2. Pharmacological: SSRIs (Fluoxetine, Sertraline+CBT, Venlafaxine)* * Evidence-based treatment for social anxiety disorder combines social skills training and behavioral therapy in group and individual sessions. Included lessons on initiating and maintaining conversation, joining groups of peers, nonverbal skills like eye contact and “peer generalization” of the skills (Lewis)*

Answer 428

* differences **in sources of anxiety**= for example, for adolescents, one of the main themes of anxiety is related to rejection from peers, whereas in the younger population, themes of anxiety may be more likely related to fear of separation from parents, fear of death * **Expression of anxiety**: children are more likely to express anxiety symptoms as somatic complaints, have tantrums/crying/freezing/clinging as compared to adolescents * younger children are more likely to experience separation anxiety vs adolescents, who are more likely to experience SAD

Answer 429

- parental overprotection and intrusiveness - heritability/family history - major life stressors (death of a family member, parental divorce) - modelling from parents/family - innate temperament

Answer 430

1. PMHx and physical exam 2. CBC with differential with particular attention to the WRC and neutrophil count 1. treatment should not be initiated if the WBC count is less than 3.5x109/L and/or the absolute neutrophil count (ANC) is less than 2.0x109/L, or if the patient has a history of a myeloproliferative disorder, or toxic or idiosyncratic agranulocytosis or severe granulocytopenia 3. Fasting Blood Glucose – baseline, repeat at week 12, then repeat annually 4. Fasting lipid profile – baseline, repeat at week 12, then repeat at least q5years or more frequently 5. Serum C-reactive protein – baseline, day 7, day 14, day 21, day 28 6. Troponin levels - baseline, day 7, day 14, day 21, day 28 7. Serum potassium & magnesium levels – baseline; periodically during treatment 8. ECG – baseline 9. Echocardiogram – baseline 10. BP & HR – baseline, and then pre- and post-dose during initial number of doses 11. All vital signs – baseline and then q2days x first 28 days 12. Weight and BMI – baseline, week 4, week 8, week 12 and then quarterly 13. Waist circumference – baseline and then annually 14. EEG - baseline

Answer 431

1. Consent, including sharing info with Gencan 2. Pre treatment assessment 3. Send registration forms to Gencan 4. Start dose 12.5 mg once or twice/ day. For day one and day two of treatment orthostatic blood pressure (sitting and standing) should be taken 6-8 hours post dose 5. Monitor for fever at day 1 and 2 of tx

Answer 432

1. If Clozapine treatment stops for 48 hours it is recommended that the patient’s dose return to 12.5 mg and be re-titrated. The blood monitoring frequency may remain the same 2. If Clozapine treatment is interrupted for more than 72 hours but less than 1 month it is recommended that the patient’s dose return to 12.5 mg and is re-titrated. It is recommended the blood monitoring frequency return to weekly for 6 weeks. 3. If Clozapine treatment is interrupted for more than 1 month the patient should be treated as a new start

Answer 433

CBT: structured and time limited therapy focused on symptoms premise that depression maintained by maladaptive behaviours and inaccurate thoughts and beliefs about self, others and future influenced by depression. Ix try to work through thoughts and evaluate accuracy negative thoughts and beliefs. Behaviours to increase pleasure. IPT: time limited therapy based on premise that our relational stressors including loss, change, transition, disagreement or sensitivity associated w/ onset or perpetuation of sx. Similar/diff: both time limited, structured therapies focused on present and symptoms at this time. IPT has 4 specific focuses and looks through a relational lens while CBT focuses on core beliefs and negative inaccurate thoughts. More structured with homework and can be administered via telephone of internet. Scales to monitor progression. All sessions start with setting agenda. 3 phases of IPT. 12-16 sessions. Therapist directive. IPT- psychodynamic origin versus CBT.

Answer 434

Grief Role Dispute Role Transition Interpersonal Defiicts

Answer 435

1. Focal area: Role transition (grief, role transition, IP sens, role dispute). 1. Start sessions with IP inventory, 2. develop rapport, 3. explain therapy, 4. assign sick role and choose focus. 2. Intermediate: work on comm analysis and bring back to focus area. What she has gained/loss with transition. 3. Termination: emphasize progress (scales) and work on relapse prevention, problem solving. If not successful blame therapy not pt.

Answer 436

* CBC, lytes, CAMP, albumin, LFTS, Cr, Urea * ECG

Answer 437

Adults 1. CBT Modified for BN (most evidence) 2. IPT (as effective as CBT, but slower) 3. DBT (case reports) Adolescents 1. Family Based Therapy (superior to supportive and CBT) 2. CBT for BN (not as effective as FBT)

Answer 438

Naltrexone 50 mg + relapse prevention techniques

Answer 439

Intellectual Disability

Answer 440

Slow Waves

Answer 441

Candidate will review that to be found unfit to stand trial the patient must be unable on account of a mental disorder (any disease of the mind) to: (1) understand the nature or object of the proceedings, (2) understand the possible consequences of the proceedings, or (3) communicate with counsel. The exceptional candidate will know that this is from Section 2 of the Canadian Criminal Code, and the governing case law is R v Taylor, 1992.

Answer 442

The court can handle an unfit accused in 2 ways: 1. He could have been remanded directly to the provincial review board (waits in jail or hospital until review board) OR 1. A treatment order could have been obtained if the court had evidence that (a) he was suffering from a mental disorder AND that treatment with a psychotropic medication was likely to render the accused fit to stand trial in a period of 60 days maximum, (b) that without treatment the accused was likely to remain unfit, and (c) the risk of harm from the administration of medication was not disproportionate to the anticipated benefits of the treatment.

Answer 443

* “Not Criminally Responsible”. * In Canada no person is criminally responsible for an act committed or an omission made while *suffering from a mental disorder* that rendered the person *incapable of appreciating the nature and quality of the act* or omission or of *knowing it was wrong*. This is from Section 16 of the Canadian Criminal Code.

Answer 444

* Child Abuse * Driving * Gunshot * Health card fraud * Sexual misconduct (ex by a regulated health professional) * Railway safety (ex train conductor) * Aeronautics safety (ex pilot or air traffic controller) * Court order

Answer 445

* Supreme Court of Canada has held that a physician was permitted to warn police when aware of the serious, imminent danger posed by a patient to an identifiable group against whom the patient had made specific threats * A duty exists where there is * (1) a risk to a clearly identifiable person or group of persons * (2) the risk of harm includes severe bodily injury, death or serious psychological harm, * (3) element of imminence and sense of urgency.

Answer 446

* If the patient is not capable, they need to be informed of the finding of incapacity and that a substitute decision maker (SDM) will be sought. * The patient is informed that they have the right to challenge this decision if they do not agree. The finding and reasoning behind it must be documented. * A Form 33 is filled out and given to psychiatric inpatients in Ontario. * An SDM has to be over 16 and capable to make the decision and willing to take the role. The approved (hierarchical) list legislated in Ontario by the HCCA is: * Anyone appointed by the court or CCB * Power of Attorney if it exists * Spouse/Partner * Child/Parent * Parent with right of access * Sibling * Any other relative

Answer 447

* **Schizophrenia:** * Primary symptoms are psychosis (delusions, hallucinations, disorganized thoughts, disorganized / catatonic behaviour, negative symptoms) * No major depressive or manic episodes occur concurrently with active phase symptoms for a prolonged duration of the illness. * If mood episodes (depressive or manic) have occurred during active phase symptoms, they have been present for a minority of the total duration of the active and residual phases of the illness. * **Schizoaffective Disorder:** * Characterized by a combination of symptoms of schizophrenia, and symptoms of a mood disorder, such as mania and/or depression. * There must be an uninterrupted period during which there is a major mood episode (manic of depressive), occurring at the same time that symptoms of schizophrenia are present. * The symptoms meeting criteria for a major mood episode must be present for the majority of the duration of illness * BUT there _must_ be psychotic symptoms (delusions or hallucinations) for at least two weeks in the absence of a major mood episode, during the course of illness * **Major Depressive Disorder:** * Primary symptoms are those required for diagnosis of depression: * five or more symptoms during the same 2-week period, at least one of which is depressed mood or loss of interest or pleasure. (Depressed mood; Anhedonia; Reduced appetite or weight loss; Slowed thoughts or movements; Reduced energy; Feelings of worthlessness or guilt; Reduced concentration; Recurrent thoughts of death or suicidal ideation) * If there are psychotic symptoms, these resolve as depression improves (often first Sx to improve) and do not persist after depression resolves

Answer 448

Nasuea/Vomiting Bradycardia Sedation Hypotension

Answer 449

Confirm compliance Rule out substance use Start clozapine (best if olanzapine was one of meds tried)

Answer 450

* Major mental illness, where stirring up affect may lead to decompensation of their illness * Violence in family * Inflexible in considering there may be a problem in family * Therapy counter to family belief systems * Key members in family don’t participate * Where FT is not first line treatment; eg. Detoxing or treating a psychosis

Answer 451

Propranolol = first line Benztropine = second line Benzos = non-responders

Answer 452

Pragmatic language

Answer 453

Ventricular enlargement Reduced voume of corpus callosum Increased periventricular white matter changes

Answer 454

Pregnant Using Opioids LFTs 3x upper limit normal or cirrhosis (needs FU liver enzymes after 3 weeks)

Answer 455

Family Intervention - reinforce more prosocial behaviors and to diminish undesired behaviors at the same time (form of CBT) Individual Play therapy - sometimes benefit

Answer 456

Amygdala Hyperactivity

Answer 457

SI (7x) Depression mania delirium confusion disorientation

Answer 458

Depression Suicide risk (case reports) Psychosis

Answer 459

Hypophosphatemia (most concerning aspect of refeeding syndrome) Also: * Hypokalemia * Congestive heart failure * Peripheral edema * Rhabdomyolysis * Seizures * Hemolysis

Answer 460

Reassure they will improve with time - indications for nocturnal polysomnography (PSG) include - •Habitual snoring, observed apneas, nocturnal enuresis, or other symptoms suggesting OSA. - •Significant safety concerns, excessive disruption of the family members' sleep, or contemplation of pharmacotherapy. - •Atypical features that raise concern for nocturnal seizures, such as daytime neurologic symptoms, older age group, family history of seizures, and multiple occurrences on a single night

Answer 461

* CBT, IPT, DBT * Imipramine, sertraline, citalopram, topiramate (Grade a evidence) * Vyvanse approved for moderate to severe BED

Answer 462

Adults * depression * anxiety disorders * suicidality and self-harming behaviors * substance abuse. Children * depressive disorders * anxiety disorders * impulse-control disorders.

Answer 463

Stereotypic movement disorder \*Note * Stereotypic movement disorder - Repetitive, seemingly driven, and apparently purposeless motor behavior (e.g., hand shaking or waving, body rocking, head banging, self-biting, hitting own body).Interferes, occurs in early developmental period * DCD - motor skills far below what is expected for developmental age

Answer 464

* Depression (acute, recurrent, maintenance, subsyndromal, geriatric, adolescent, HIV+, postpartum, antepartum) * Adjunctive Tx in BAD * Bulimia * Initial/limited evidence in * Dysthymic disorder * Social phobia * PTSD

Answer 465

* Stop offending agent * Admit to ICU * Provide supportive care - airway, fever, fluids * Involve CL psych early * Possibly use cyproheptadine (5HT2a-blocker) or benzos

Answer 466

Phyostigmine

Answer 467

diaphoresis

Answer 468

family history affective disorder

Answer 469

Patient must be able to understand 1. Understand harges & potential consequences 2. Understand and enage in Trial process 3. Capacity to participate with an attorney in a defense 4. Potential for courtroom participation

Answer 470

Children require higher by weight doses than adults

Answer 471

Advance parental age Prenatal Factors * advanced maternal and paternal age at birth * maternal gestational bleeding * gestational diabetes * first-born baby Perinatal Risk Factors * umbilical cord cx * birth trauma * fetal distress * SGA * low birth weight * low 5 min apgar score * congenital malformation * ABO/Rh blood factor incompatibility * hyperbilirubinemia

Answer 472

* Focus on the interpersonal relationships and how this relates to the onset/maintenance of the depression * Based on the biopsychosocial model * Aim is to alleviate suffering and improve interpersonal functioning * May also help to improve the patient’s social network so they are better able to manage their interpersonal distress * Affective expression encouraged (especially emotions related to mourning or loss of social roles) * Time limited (usually between 12-16 sessions) * Dynamically informed therapy but the focus is here-and-now and the interventions used do not directly address the patient-therapist relationship

Answer 473

* CBT is based on the cognitive model of mental illness, initially developed by Beck (1964). * People’s emotions and behaviours are influenced by their perceptions of events. * How people feel is determined by the way in which they interpret situations rather than by the situations per se. * Three levels of cognition: * Core beliefs * Dysfunctional assumptions * Negative automatic thoughts

Answer 474

* Antipsychotic drug treatment can cause tardive dyskinesia, it can also mask/suppress tardive dyskinesia * Antipsychotic withdrawal or dosage reduction can unmask tardive dyskinesia; and thus, tardive dyskinesia can appear to worsen after dosage reduction or discontinuation of the perceived offending agent. * Although use of first generation antipsychotics are associated with a higher risk of tardive dyskinesia, second generation antipsychotics are not free from risk of tardive dyskinesia

Answer 475

* Reports of risk vary * 5% yearly incidence for tardive dyskinesia on first generation antipsychotics compared to a 1% incidence on a second generation antipsychotic. * There is currently insufficient data to determine differences in risk between different second generation antipsychotic drugs. * clozapine carries the lowest risk for tardive dyskinesia.

Answer 476

* The most clearly established risk factor for tardive dyskinesia is age. Although figures vary, in patients over 65, the risk of TD is at least double – and in some studies up to 5X as high – as compared with a younger population. * Other risk factors include: * duration of antipsychotic treatment * previous head injury * mood disorder * possibly female gender * possibly dose * possibly early presence of significant EPS. * Iron deficiency can be a risk factor for exacerbation of movement disorders

Answer 477

* Beyond lips, tongue and jaw, one needs to assess the face for grimacing movements and abnormal eye blinking. * Choreoathetoid movements in fingers, wrists, ankles and toes * Rocking or torsion movements of neck and/or trunk. * Diaphragmatic involvement, which may result in grunting or non-rhythmic breathing. * Other late-onset movement disorders associated with chronic antipsychotic treatment, including tardive dystonias and tardive akathisia.

Answer 478

* There is no good evidence for any specific drug treatment for tardive dyskinesia. * TD may gradually improve over time (months or years) if the offending agent is withdrawn. * Can switch patient to an antipsychotic medication with less propensity to cause TD. * The data is strongest for clozapine as it appears to have the lowest risk for TD. * Switching from an older generation antipsychotic to another second generation atypical antipsychotic may also be helpful.

Answer 479

* In off-label use of a drug, one needs to inform the patient that the drug is not approved for the purpose for which you intend to prescribe it. One would also provide information on the benefits and risks in the same manner as would for an approved drug. For a non- approved use however, there may be less good information on risks and benefits. * Additional caution and judgment is required when prescribing a drug for a non-indicated use. The physician must distinguish between off-label use where safety and efficacy is reasonably well-established versus off-label use based on anecdotal reports, open label studies, a single small RCTs, poorly designed studies, etc.

Answer 480

AIMS - TD Simpson Angus Scale - EPS Barnes Akathisia Scale - Akathisia

Answer 481

* Dialectical behavior therapy (DBT) is the psychosocial treatment that has received the most empirical support for patients with borderline personality disorder * Method is eclectic, drawing on concepts derived from supportive, cognitive, and behavioral therapies. * 4 primary modes of treatment in DBT: group skill training, individual therapy, phone consultation, and consultation team. * Seen weekly, with the goal of improving interpersonal skills and decreasing self-destructive behavior. * Patients with BPD receive help in dealing with the ambivalent feelings that are characteristic of the disorder * DBT assumes all behavior (including thoughts and feelings) is learned and that patients with borderline personality disorder behave in ways that reinforce or even reward their behavior, regardless of how maladaptive it is

Answer 482

1. use the same medication for tapering 2. switch to a longer-acting equivalent 3. use adjunctive medications to help mitigate potential withdrawal symptoms. - Initial reduction of 25-30% for high dosage chronic users, followed by a 5-10% daily to weekly reduced dose.

Answer 483

* RAD = A) The child rarely or minimally seeks comfort when distressed. AND/OR responds to comfort when distressed. WITH persistent emotional disturbance * Before Age 5 * DSED = A) Reduced or absent reticence in approaching and interacting with unfamiliar adults. Overly familiar verbal or physical behavior (that is not consistent with culturally sanctioned and with age-appropriate social boundaries). Diminished or absent checking back with adult caregiver after venturing away, even in unfamiliar settings. Willingness to go off with an unfamiliar adult with minimal or no hesitation * Both * The child has experienced a pattern of extremes of insufficient care as evidenced by at least one of the following: Social neglect or deprivation in the form of persistent lack of having basic emotional needs for comfort, stimulation, and affection met by caregiving adults. Repeated changes of primary caregivers that limit opportunities to form stable attachments (e.g., frequent changes in foster care). Rearing in unusual settings that severely limit opportunities to form selective attachments (e.g., institutions with high child-to-caregiver ratios). * Must be 9 months of age

Answer 484

Paranoid delusions (somatic delusions also very common)

Answer 485

Female gender Poor Prognostic Factors in BAD * older age * male * psychosis * mixed episodes * substance use * younger onset * rapid cycling

Answer 486

Derouting conflict through a child

Answer 487

* food restriction * excessive exercises * preoccupied with food, eating, calories * social isolation * mood irritability, depression, obsessive compulsive behaviour * cold intolerance * lanugo hair * hair loss * poor sleep (early am waking) * dizziness, fainting * GI symtpoms

Answer 488

*DSM 5 criteria for Stimulant Intoxication:* Two (or more) of the following signs or symptoms, developing during, or shortly after, stimulant use: 1. Tachycardia or bradycardia. 2. Pupillary dilation. 3. Elevated or lowered blood pressure. 4. Perspiration or chills. 5. Nausea or vomiting. 6. Evidence of weight loss. 7. Psychomotor agitation or retardation. 8. Muscular weakness, respiratory depression, chest pain, or cardiac arrhythmias. 9. Confusion, seizures, **dyskinesias**, dystonias, or coma.

Answer 489

Opioid partial agonist at MU receptor

Answer 490

male gender Rapid Cycling RF * Younger, onset \<17 * Women \> men (70%) * Hypothyroidism \*\*\* NOT hyperthyroid * SSRIs

Answer 491

substance cues to use lead to glutamate mediated activation

Answer 492

propanolol

Answer 493

CBT * Recall * KS - primary treatment of ODD is family intervention using both direct training of the parents in child management skills and careful assessment of family interactions. * The goals of this intervention are to reinforce more prosocial behaviors and to diminish undesired behaviors at the same time * CBT - teach parents how to alter their behavior to discourage the child's oppositional behavior by diminishing attention to it, and encourage appropriate therapy focuses on selectively reinforcing and praising appropriate behavior and ignoring or not reinforcing undesired behavior

Answer 494

Predictive of BAD in later life

Answer 495

* 250-300ng/L normal target OR 1000-2500nmol/L * 50 – 150 =low * 200 – 300 good initial target * 350 – 400 could be tried if response insufficient

Answer 496

CBT is an effective first line option (TF-CBT, EMDR, PE, and stress management therapy)

Answer 497

CBT is equally effective as medication and CBT combination

Answer 498

As per the CADDRA Guidelines, Parent Training interventions such as **Incredible Years, Triple P Parenting, and Parent-Child Interaction Therapy** are evidence-based interventions to target oppositional and disruptive behaviours in ADHD. The central principles are: 1. Consistently **reinforcing positive** behaviours 2. **Ignoring low-level provocative** behaviours 3. Providing **clear, consistent, safe responses to unacceptable** behaviours

Answer 499

Anxiety or panic attack-like symptoms Impairment in short term memory Impairment in motor skills Impairment in attention Acute/transient psychosis Toxicity Impairs concentration and reaction time as well as attention and coordination Makes it harder to learn and remember things Affects mood and feelings (anxiety, panic, fear) Affects mental health (can trigger a psychotic episode)

Answer 500

Effective parenting: warmth and nurturance along with effective discipline and limit-setting Healthy Parent-Child relationships: characterized by warmth, supportiveness, effective problem-solving skills, positive communication, and low levels of conflict and negativity Protection from conflict between parents Cooperative parenting Household structure and stability

Answer 501

A) CD likely, because \<18. Recall, in Cd, symptom clusters are: *Aggression* * Destruction of Property* * Deceitfulness/Theft* * Serious violation of Rules* * B) ASPD* * C) BPD* * D)* **Multimodal treatments - behavioral interventions rewarding prosocial and nonaggressive behaviors, social skills training, family education and therapy, and pharmacologic interventions** * An environmental structure that provides support, along with consistent rules and expected consequences * **A Violence and Aggression prevention plan in school** * Parental Psychiatric Assessment & Intervention if necessary * Behaviorally based individual psychotherapy targeting problem-solving skills with appropriate rewards * Group therapy if imobilized/insitutionalized (You need 3/12 symptoms of make a diagnsois of CD)

Answer 502

Good family functioning Parents who believe the medical disorder is serious and that the treatment is effective Having close friends An internal locus of control Perceived empathy from one’s clinician**Greater illness severity scores** **Medication tolerability** (Adverse effects of medications) Higher sensitivity to metabolic and CV risks on this population **Complicated (\>1x daily) dosing schedules** **Complex medication regimens** Cognitive Difficulties/ Developmental Stage/ Concrete Thinking **Denial of One’s Illness** Concerns about BAD as part of one’s identity; **fitting in with peers** Impaired Family Functioning Need for **monitorin**g of some medications Polypharmacy Time since follow-up **Undertreatment** (leading to belief that med is ineffective)

Answer 503

{a} 1 neuropsychiatric symptom: motor skills neuroanatomy/neurophysiology cognition language academic achievement memory attention executive function, including impulse control and hyperactivity affect regulation adaptive behaviour social skills social communication. {b} 1 behavioural symptom: Aggression Insomnia Agitation Anger Mood Swings Restless movement {c} 2 impacts on adaptive functioning: adaptive skills significantly below cognitive potential global cognitive or intellectual deficits representing multiple domains of deficit social skills social communication. Documented dysfunction in meeting key adaptive functioning goals – hygiene expected for age, follow safety rules etc Documented difficulty in social competence as manifested by being financially victimized or unintentionally involved in criminal behaviour due to social gullibility a {d} 1 comorbidity: ADHD, tic disorder, learning disorder

Answer 504

1. A tic is a **sudden, rapid, recurrent, non-rhythmic** motor **movement or vocalisation** (DSM-5). 1. Alpha-2 agonists (clonidine and guanfacine); Risperidone; Tetrabenzine 1. Tourette Syndrome is often mild and therefore no treatment is required. In general terms, one needs to **initiate treatment when the symptoms are distressing and/or when symptoms interfere with function** **Majority of patients symptoms improve** substantially by the end of adolescence, providing a clear diagnosis and information about etiology, prognosis and treatment options is reassuring and may be the only intervention required. When treatment is necessary one should select an effective treatment with the least likelihood of inducing adverse effects following the appropriate evidence based treatment guidelines.

Answer 505

anxiety must occur in peer settings, and not just during interactions with adults. may be expressed by crying, tantrums, freezing, clinging, shrinking failing to speak in social situations

Answer 506

_Risk Factors for Early Onset_ * paternal age * in utero exposure to maternal malnutrition or infectious agents * cannabis use during adolescence * Immigration * Family history of psychiatric conditions in first degree relatives * Place of Birth (urbanicity) * Season of birth * Pre-natal and Peri-natal Risk Factors * complications of pregnancy (bleeding, diabetes, pre-eclampsia) * abnormal intrauterine development (low birth weight, congenital malformations, reduced head circumference) * complications of delivery (\*\*hypoxia, uterine atony, asphyxia, emergency Caesarean section) * Also, APSS, BIPS & Genetic Risk & Deterioration (GRD) _Early Intervention Approaches (Canadian Schz Guidelines)_ * **Urgently refer to specialized mental health/early psychosis clinic** * **Offer antipsychotic medication in conjunction with psychological/psychosocial interventions (once dx confirmed)** * **Discuss use of cannabis and substances** * **Clinicians should work in partnership with parents or carers, as well as children and young people with schizophrenia, while taking into consideration their developmental level, emotional maturity and cognitive capacity. (Family-based, psychoeducation, communication, problem-solving)** * Encourage parents to seek their own support * Offer **CBT** to assist in promoting recover * Offer employment programs to young people with schizophrenia who wish to find or return to work * Consider supported education programs * Clinicians should give children and young people with schizophrenia, and their parents or carers, information regarding psychosis or schizophrenia * Cognitive remediation therapy may be considered for young individuals diagnosed with schizophrenia who have persisting problems associated with cognitive difficulties

Answer 507

* Drugs * Medication overdose (intentional or accidental) - sympathomimetic, serotonin syndrome, sedative-hypnotic (?), hallucinogenic, anticholinergic * Intoxication – alcohol, Hallucinogen, stimulant, sedative-, hypnotic- or anxiolytic- * Withdrawal – cannabis, alcohol, stimulant, sedative-, hypnotic- or anxiolytic- * Infectious/Inflammatory * Sepsis * CNS infection such as meningitis * Pneumonia * Urinary/STI * Encephalitis (eg anti-NMDA) * Metabolic/Endocrine * DKA/hypoglycemia * Thyrotoxicosis * Structural * brain injury, subdural hematoma, post-ictal, stroke, tumour, brain mets

Answer 508

* Definition: Mindfulness (or MBSR) practices focus on paying sustained attention to moment-to-moment stimuli without engaging in cognitive judgments or self-criticism, and promoting an attitude of acceptance. (KS 31.18) * Mindfulness vs Relaxation/Meditation: mindfulness practices teach *acceptance of present moment internal events*, while relaxation practices *teach strategies to change internal events.* (Eg. Body Scan/Breath Awareness/Sitting meditation vs. Progressive Muscle Relaxation/Deep Breathing/guided imagery) * Differences in intention generally come down to accepting internal events (mindfulness) and changing internal events (relaxation). [[i]](#_edn1) * Classical CBT focused on focused on directly changing individuals’ thoughts, emotions, physical sensations, and behaviors using strategies such as cognitive restructuring, behavioral experiments, and relaxation techniques * Classical/traditional CBT mphasized relaxation practices as a way to change uncomfortable internal experience * Third-wave CBT interventions emphasize mindfulness practices over relaxation practices to help patients develop open, nonjudgmental, and nonreactive relationships to internal experiences. * Core components of mindfulness in third-wave CBT include present moment awareness, attention regulation, and a nonjudgmental attitude * Examples of Third-Wave CBT interventions include: Mindfulness-Based Stress Reduction (MBSR), Mindfulness-Based Cognitive Therapy (MBCT), Dialectical Behavior Therapy (DBT), Acceptance and Commitment Therapy (ACT), and Acceptance-Based Behavior Therapy (ABBT)

Answer 509

Pros: Increased access and reach Support prevention and early intervention Fewer barriers to care Reduce stigma Cons: Generally no parent or caregiver involvement May not reach children with school avoidance Barriers: Lack of trained personnnel Resource and financial limitations including competing demands on educator and school personnel time Generally less evidence base than clinic-based interventions

Child & Adolescent Psychiatry Flashcards

(546 cards)