Child psychology

Question 1

Development Infancy: Explain From delivery to 2yrs

Answer 1

• Premature infants (<34wks) are at increased risk of Dyslexia, behavioural problems, developmentally delayed, mental retardation and child abuse. (Also their parents are at risk for PTSD)
• By the end of Infancy these basic areas have developed intention

Question 2

Development Infancy: Explain Reflexes

Answer 2

Rooting, Grasp, Babinski (up), patellar, Moro (Startle), and Tonic Neck.

• Grasp, startle, and tonic neck tend to disappear by 4mo
• Babinski is down by 12mo.

Survival Systems work, but needs more external input for neurophysiological functions

Question 3

Development Infancy: Explain Language and thinking

Answer 3

Guttural or babbling will emerge around 8wks (especially for mom)

Question 4

Development Infancy: Explain Emotional/Social development

Answer 4

• By 3wks they imitate adults, may be precursors to further emotional life
• Smiling - endogenous with in 2wks, exogenous with in 4mo.
• Temperament (Chess and Thomas)
  
  • some aspects persist into adult life (calm), others extinguish.
  • Activity Level, Distractibility, Adaptability, Attention Span, Intensity, Responsiveness, Quality of mood, Rhythmicity, Approach/Withdrawal.

Question 5

Development Infancy: Explain Attachment

Answer 5

• Bonding: relationship mother develops towards baby
• Attachment: relationship baby develops towards mom
• Harry Harlow: Effects of social isolation in monkeys
• John Bowlby: defined attachment as maintenance of physical contact when infant is hungry, frightened or in distress.
• Mary Ainsworth: The Strange Situation Three major Attachment styles
  
  • Secure
    
    • Babies go off and explore, mom is a “secure base”. Get distressed when mom-leaves or becomes unresponsive, easily and quickly comforted when mom is back, then return to play. Tend to show fewer adjustment problems.
  • Insecure-Anxious/Avoidant/Resistant
    
    • Babies tend to cling to mom, less likely to explore. Get distressed when mom leaves/becomes unresponsive, are angry/hard to comfort when mom returns. Parents are likely to become rejecting.
  • Insecure- Ambivalent/Avoidant
    
    • Babies explore ignoring presence of mom, do not check in with her. Not distressed with mom-leaves or becomes unresponsive, and do not particularly require comforting. Do seek mom with stranger, or fear and are inconsolable.
  • Attachment decreases anxiety, and transitional object may serve as a secure base.
  • With progressively more children attachment for older children is lessened.
• Spitz: Deprivation and neglect causes mental retardation
• Stranger Anxiety:26wks-32wks. Separation Anxiety: 10-18 mo.
• Parental Fit, and “Good Enough Mothering”
  
  • 40% of infants are “easy”, 10% are hyper alert, 50% are a mix of both these traits. If parenting style does not fit everyone is distressed.
  • Mom’s don’t have to be perfect, but should respond to the babies Needs.

Question 6

Development Toddlers and Preschool: Explain Language and Cognitive

Answer 6

Start with 2 word sentences, end with real sentences. Memory improves, limited use of logic.

Toddlers start to listen to explanations, and start to tolerate delay, varied capacity for Self Regulation,

Pre-schoolers start using sentences, and thinking symbolically. However still very ego-centric

Question 7

Development Toddlers and Preschool: Explain Emotional and Social

Answer 7

Toddlers start to copy others in how to respond to new events. They are exploring and excitable!

Pre-schoolers feelings are driven by somatic changes, but can tolerate anxiety more. Responses to environment less emotions themselves

By the end of pre-school tend to have stable emotions, and develop empathy, can feel guilty.

PLAY

• Toddlers play independently, not often with others.
• Pre-schoolers engage in Parallel play, then associative play
• By age 4 begin cooperative play.

Imaginary Friends

• Appear in preschool, usually friendly humans. Can be things.
• Up to 50% between age 3-10 will have them at one time.
• Usually disappears by age 12.

Question 8

Development Toddlers and Preschool: Explain Sexual and Genital

Answer 8

• Toddlers begin to manifest Gender identity at age 18mo, usually fixed by 30mo.
• Gender Role describes behaviour and is not correlated with identity.
  
  • However, starts to be applied to children immediately. Moms talk to girls more, etc..
• Toilet Training: Control of urination in day time b 2.5yrs, in night by age 4. Bowel control by age 4.
• Between age 3-6 start noticing differences in bodies of different sexes, play doctor.
• Age 3-6 have preoccupation with bodies in general and is often called the “band aid phase”

Question 9

Development “The Middle Years” Age 6- Puberty: Explain Language and Cognitive Development

Answer 9

In school and demands for academic learning become determinants of personality

• Language and Cognitive Development
  
  • Increased self regulation, by age 9-10 can voluntarily concentrate (This does require practice)
  • Maturational changes in brain leads to increased independence, learning, socialization, moral development.
  • Start to identify with adults in their lives regarding gender roles
  • Peer interaction becomes more important, but prefer same sex interaction.
    
    • Sex play/ comparisons are common especially in boys
    • Best Friend by age 10, usually same sex
    • School refusal: Separation anxiety, transference related to mom (from mom separating from kid)

Question 10

Development “The Middle Years” Age 6- Puberty: Explain Sexual Role Development

Answer 10

There are currently many changing social rules/expectations. This can be hard for children without clear guidelines or support.

Question 11

Development “The Middle Years” Age 6- Puberty: Explain Dreams/Sleep

Answer 11

• Age 4: understand dreams are individual
• Disturbing dreams peak at 3,6, and 10 (transitions)
• Age 5: realize that dreams are not real.
• Age 2 need 30 min to fall asleep.
• Disorders with sleep are usually related to dreaming, and need rituals to protect themselves.

Question 12

Development Family Factors: Explain Parenting Styles (Rutter)

Answer 12

• Authoritarian- Strict inflexible rules, may cause low self-esteem, and social withdrawal. (strict rules, less level of support)
• Indulgent-Permissive- little to no limit setting, unpredictable parental harshness. Low self-reliance, poor impulse control, aggression. (low rules and level of support)
• Indulgent- Neglectful- non-involvement in child’s life/ rearing. Child may develop low self-esteem, poor self control, aggression.
• Authoritative Reciprocal- firm rules and shared decision making in loving environment. Results in self reliance, and social responsibility.

Question 13

Development Family Factors: Explain Divorce (30%-50% of kids live in single parent households)

Answer 13

• Infants- Don’t notice
• 3-6yrs- don’t understand, or assume its their fault (egocentric)
• Older children understand, (especially adolescents)
  
  • May believe they could have prevented the divorce
  • May be supportive of divorce- especially if teenager
  • Adaptation takes several years.
  • Demographically at risk for many poor outcomes (historically)
• Types of Stepfamilies
  
  • Neo-Traditional: absent parent included sometimes, discipline is discussed openly, taking sides is avoided.
  • Romantic: expect to be “Traditional” immediately, absent parent is criticized, difficulty with step parent, few open discussions.
  • Matriarchal: Run by a competent mom, companion follows. Companion is “buddy” for kids, not a parent, birth of step-sibling causes problems.

Question 14

Explain Development Adolescense (5 Stages / Year Groups)

Answer 14

• “Normality” describes amount of adaptation achieved while navigating hurdles and milestones.
• Role confusion (Erikson)
  
  • Integration of past with current changes and expectations.
  • Identity Crisis is Normal, bonding with peers and experimenting is common.
• Early Adolescence (12-14yrs)
  
  • Initial physical changes (Growth Spurts) embarrassment about body
  • Start to criticise family, spending time with family and less supervision.
  • Increased interest in opposite Sex
• Middle Adolescence (14-16yrs)
  
  • Continue to try being more independent from family
  • Sexual behaviour increases
  • Self-esteem is critical to modulate risk taking.
  • Sense of Omnipotence
• Late Adolescence (17-19yrs)
  
  • Continued exploration of academic and artistic tastes
  • Greater definition of self and belonging to groups
• Cognitive Maturation (into late 20s)
  
  • Transition from concrete to more abstract. Increased awareness of self.
  • Omnipotence transitions to strategies to promote ones strengths and compensate for weaknesses
  • Morality develops as cognition matures.

Question 15

What are the Normal Milestones?

Answer 15

Question 16

What are the Development Theories? (In Review)

Answer 16

Question 17

Which Genetic Disorder is this?

Trisomy 21, 15/10000 of live births (very common question)

Physiology- Slanted eyes, epicanthal folds, flat nose

Etiology- Nondisjunction during meiosis, nondisjunction in fertilization, translocations

Answer 17

Down Syndrome

Question 18

Which Genetic Disorder is this?

Mutation at fragile site, 1/1000 males (very common question)

Physiology- large head and ears, short stature, hyper extensible joints, post-pubertal macroorchidism

High rate of ADHD, learning disorders, ASD, Relatively strong skills in communication and socialization

Some asymptomatic males, female carriers.

Answer 18

Fragile X

Question 19

Which Genetic Disorder is this?

deletion on chromosome 15 1/10000 births

Compulsive eating, obesity, intellectual disability, hypogonadism, hypotonic, small hands and feet.

Answer 19

Prader-Willi Syndrome

Question 20

Which Genetic Disorder is this?

Deletion on chromosome 5,

Severe mental disability, microcephaly, low set ears, oblique palpebral fissures, micrognathia

Characteristic cat like cry 2/2 laryngeal abnormalities that they grow out of

Answer 20

Cat’s Cry Syndrome (Cri-du-Chat)

Question 21

Which Genetic Disorder is this?

Autosomal Recessive, inborn error of metabolism, 1/10-15K births.

Severe disability, ECZEMA, vomiting, convulsions, temper tantrums, twisting of hands

Treat with low phenylalanine diet ASAP. If before 3mo can have normal intelligence.

Answer 21

Phenylketonuria (PKU)

Question 22

Which Genetic Disorder is this?

degenerative, dominate X gene, only affects females.

At 1yr age, Ataxia, grimacing, teeth grinding, loss of speech. Progressive motor and cerebral degeneration as well and eventual death

Answer 22

Rett Syndrome

Question 23

Which Genetic Disorder is this?

Chromosome 17 1/5000

Cafe Au Lait spots, neurofibromatosis, optic gliomas, acoustic neuromas. Causing seizure and learning disorders.

Answer 23

Neurofibromatosis 1

Question 24

Which Genetic Disorder is this?

Autosomal Dominant 1/15000

Seizures with adenomas sebaceym and ash leaf sports

Answer 24

Tuberous Sclerosis

Question 25

Which Genetic Disorder is this? X Linked Deficiency in Purine Metabolism, diet helps Compulsive self mutilation via biting

Answer 25

Lesch-Nyhan Syndrome

Question 26

What are the classifications of Intellectual Disabilities? Formally known as Mental retardation, caused by a variety of things leading to social and cognitive impairments characterized by impaired functioning.

Answer 26

* Classifications * Mild (85% of intellectually disabled, 50% with no clear cause, IQ is 50-70) * 0-5yrs- Develops social and communication skills needed, minimal retardation noted * 6-20yrs- Learns academic skills up to 6th grade of regular school by late teens, can be guided to social conformity * 21+yrs- Usually achieves social and vocational skills for self-support, may need guidance when under more stress. * Moderate (10% of intellectually disabled, IQ is 35-50) * 0-5yrs- Can talk/learn to communicate, can be managed with moderate supervision * 6-20yrs- Benefits from training in social and occupational skills, unlikely to progress pass regular 2nd grade academically. Can learn to travel alone to familiar places. * 21+yrs- May achieve self-maintenance in unskilled/semi-skilled work under sheltered conditions. * Severe (4% of intellectually disabled, IQ is 20-35) * 0-5yrs- poor motor development, speech is minimal, cannot benefit from training * 6-20yrs- can talk or learn to communicate, trained in elemental health habits * 21+yrs- may contribute partially to self care, can develop self protection skills, do well in group homes. * Profound (1% of intellectually disabled, IQ is less than 20) * 0-5yrs- gross disability, cannot function, needs constant nursing care and supervision * 6-20yrs- some motor development, may respond to minimal training in self help * 21+yrs- Some motor and speech, needs nursing care. Special Facts: * Epidemiology is difficult because many with mild disability are not recognized until middle childhood. * Schools are required by law to provide appropriate and necessary services to children with disabilities. * Special Education has changed over the years.

Question 27

* Present verbally as younger than their age, may be acquired or developmental/congenital * NO comprehension difficulty in pure expressive * May be associated with ASD, often requires testing or full diagnosis. * Limited vocabulary, simple grammar, variable articulation, “inner language” refers to appropriate use of toys, objects. * Tend to use filler words “stuff… things”, usually recognized by 18mo when child has ZERO words

Answer 27

* * * Learning and Communication DO: Explain Expressive Language Deficits

Question 28

* Impaired Sound discrimination, impaired auditory processing, or poor memory for sound sequences * Lack of understanding questions/directions, inability to follow conversation, * May be perceived as behavioural rather than a deficit. * May be due to genetics, brain abnormalities, environment, or neurological processes * Usually present before age 4, mild may present around age 7

Answer 28

* Learning and Communication DO: Explain Mixed Receptive and Expressive Deficits

Question 29

* h Sound Disorder * Difficulty producing sounds, or atypical sound (Omitting the last sounds of a word, substituting one sound for another) * Diagnose by comparing abilities to expectations. * 3yrs can articulate: m, n, ng, b, p, h, t, k, q, and d * 4yrs can articulate: f, y,,ch, sh, and z * 5yrs can articulate: th, s, and r * Not related to cerebral palsy, deafness, hearing loss, TBI, or neurological deficits.

Answer 29

* Learning and Communication DO: Explain Speech Sound Disorder

Question 30

* Begins in the first years of life, peaks at age 2, 3.5, 5-7 * Disruptions in fluency, sound/syllable repetitions, sound prolongations, dysrhythmic phonations, or pauses. Can be physical

Answer 30

* Learning and Communication DO: Explain Child Onset Fluency Disorder

Question 31

Deficits in verbal and non-verbal communication for social purposes in absence of restricted repetitive interests/behaviours.

Answer 31

Learning and Communication DO: Explain Social/Pragmatic Communication DO

Question 32

Autism Spectrum DO- includes Aspbergers **Explain the Biological Influences** Prevalence is about 8/10k, but can be diagnosed later, and more diagnoses lately, Men\>Woman (more social)

Answer 32

* Definitely heritable, but multifactorial genetics, can be coordinated with fragile X, tuberous Sclerosis, chromosomes 2, 7 * Biomarkers: 5-HT expression on platelets, mTOR synaptic plasticity system, alterations in GABA inhibition * Prenatal immune incompatibility damaging early neuronal circuits, as well as other prenatal complications * Advanced age of parents, maternal gestational bleeding, gestational diabetes, first baby * Perinatal: Umbilical cord complications, birth trauma, fetal distress, low birth weight, low 5min Apgar score, congenital malformation. * Neurological disorders: 32% have seizures, 25% have ventricular enlargement, * NO differences in parental rearing

Question 33

* Persistent deficits in social interaction across multiple contexts (social reciprocity, nonverbal communication, relationships) * Restricted/repetitive patterns of behaviour * Stereotypes or repetitive motor movements, Rigidity, restricted/fixed interests (trains, computers), or hypo/hyper reactivity to sensory inputs * Severity based on social communication impairments and restricted repetitive patterns of behaviour * Present in early development but not clear until social demands increase, cause impairment, * Not other mental disorder/ intellectual disability * +/- intellectual impairment, language impairment, genetic condition, neurodevelopmental conditions, catatonia

Answer 33

* Autism Spectrum DO- includes Aspbergers **Explain the Clinical Features (DSM-V Criteria)**

Question 34

Autism Spectrum DO- includes Aspbergers Explain DiDX

Answer 34

* Social Pragmatic Communication Disorder * Childhood Onset Schizophrenia (Rare in children less than 12) * Intellectual Disability with Behavioural Symptoms * Language Disorder * Psychosocial Deprivation- raised by wolves

Question 35

Clinical Vignette ## Footnote Johnny is a 10 yo Caucasian male who presents to the psychiatry emergency department from his school where he had been having a behavioural outburst for several hours. Per report he arrived at school late, without his backpack. When his teacher asked him about where his homework was he told her it was “none of her business” for which he was put in time out. He stayed in timeout for less than 2min before he started drawing on the chalk board in the back of the class. When his teacher instructed him to return to the timeout he told her to “Fuck off with your saggy tits”, and she called for the campus safety officer, and school counsellor to assist her. From there the episode escalated and ended up with Johnny knocking everything of all the desks and tables, throwing several chairs, tying the trash bag around his neck and threatening to bomb the school and kill himself. He required manual restraint by the school safety officer to bring him to the emergency department. On interview Johnny says he doesn’t know what happened today, that his teacher is a “bitch” and states that she just hates him. He reports that he is angry, and sad, that no one likes him and he can’t seem to do anything right. He shares that he has not lived with his parents since he was 3 and has been in foster care for along time. He is in 4th grade, and is not sure if he is in special classes or not. During the interview he repeatedly gets up and leaves walks around the interview room, requires multiple asks to answer questions, he starts drawing on the walls of the interview room with a crayon, and then starts to scratch his arm with his nails. When he notices that he has developed a light abrasion he becomes visibly excited and starts to scratch fervently. Ultimately he requires manual followed by leather restraints and IM STAT medication to stop scratching. What is wrong with Johnny?

Answer 35

* Nothing * Oppositional Defiant Disorder defiant to teacher only 18-24 mos. * Conduct Disorder * Intermittent Explosive Disorder * Disruptive Mood Dysregulation Disorder * Bipolar Disorder * Depression * Anxiety * PTSD * DRUGS * #StraightUp Demon child.

Question 36

* Etiology * Normal oppositionality peaks at 18-24mo, and in “Terrible Twos” * Developmental stage increases, authority figures over-react, oppositionality persists * Temperamental Predispositions: Strong will, strong preferences, assertiveness, * Clinical Features * A pattern of angry/irritable mood, argumentative/defiant behaviour or vindictiveness for 6+ mo with 4+ of below against person who is NOT a sibling (longer than it should be causing problem) * Angry/Irritable mood * Loses temper often, easily annoyed/touchy, often angry/resentful * Argumentative/Defiant Behaviour * Often argues with authority figures, actively defies or refuses to comply with rules, deliberately annoys others, blames others for mistakes * Vindictiveness * Spiteful or Vindictive at least twice within the past 6mo. * Defy others, deliberately annoy others, blame others for their mistakes/behaviour * May only occur at home, or only outside of home * Often rejected by peers, becoming isolated and lonely

Answer 36

* * * What are the clinical and etiological points with Oppositional Defiant Disorder?

Question 37

Enduring patterns of aggressive behaviours that violate the basic rights of people * Etiology- precursor for antisocial disorder. Bed wetting at an older age * Impulsivity, physical/sexual abuse/neglect, poor parental supervision, harsh discipline, low IQ * Parental factors: harsh punitive parenting, severe aggression, chaotic home * Genetics: possible X-linked monoamine oxidase (if put in a loving caring environment would not have developed it) * Increased population density * Poor emotional regulation, poor modelling of impulse control * Decreased Grey matter, small amygdalas (don’t respond to fearful situations the way other kids would, not afraid of consequences of risky behavior and take a lot of risks; no facial emotional recognition) * Clinical Features * Not young children. Usually 10-14yo (girls older) * Repetitive and persistent pattern of behaviour that VIOLATES the basic rights of others * Aggression towards people and animals * Bullies others, initiates fights, has used a weapon, cruelty to people/animals, stolen while confronting victim, forced someone into sexual activity * Destruction of Property- Fire setting, destroying others property * Serious Violations of Rules * Stays out all night at age 13, doing drugs, run away from home twice or more, truant from school

Answer 37

* * What are the clinical and etiological points with Conduct Disorder?

Question 38

What does the following information describe? * Severe, developmentally appropriate, and recurrent temper outbursts with persistent angry mood in ages \<10yo (difference between bipolar and being angry all the time) * No Epidemiological or Etiological Data YET * Clinical Features * Outburst that are much greater than situationally appropriate, 3+ in a week. * Destroy property, threat to others * Symptoms before age 10, last for 1yr, present in 2+ Settings * Between episodes persistently irritably * Kids don’t express depression the same way adults do but is similar

Answer 38

Disruptive Mood Deregulatory Disorder

Question 39

What does the following point to (Disorder)? * Recurrent behaviour outbursts representing a failure to control aggressive impulses as manifested by: * Verbal/Physical aggression toward property, animals, or people occurring 2x wk. for 3+mo * Does not result in damage/ destruction of property or physical injury * 3 behavioural outburst resulting in physical injury against animals or people within 12 mo period. * Magnitude of aggressiveness is grossly out of proportion to provocation * Outburst are not premeditated are not committed to achieve some tangible objective * Do get happy in-between. And apologetic afterword

Answer 39

Intermittent ExplosiveDisorder

Question 40

What disorder are we referring to? * A RARE Disorder, usually becomes adult \_\_\_\_If post-pubertal onset * Prepubertal children don’t have discrete mood episodes, “Atypical” * Mood dysregulation, temper tantrums, intermittent aggressive/Explosive behaviour, distractibility/inattention * Etiology * Genetics: 60-90% hereditability, but with non-discrete episodes don't see heritability * In children of bipolar pts, 25% develop mania by age 17yo (50% chance if parent is bipolar) * “Early onset” is associated with poor response to lithium, greater co-morbidity, more mixed episodes, more psychosis * Early onset has smaller amygdala volume * Impaired verbal memory, processing speed, executive function, working memory, and attention. * More errors with emotional recognition. Adults=Angry * Clinical Features * Extreme irritability that is severe and persistent may include aggressive outbursts and violence * Between outbursts they may be angry or dysphoric. * Not usually grandiose, or euphoric (unlike in adults). Overriding negative mood * Many Comorbid disorders (ADHD, Anxiety DO) * Treatment * Pharmacotherapy, psychoeducation, psychosocial interventions (biggest intervention) * Atypical Antipsychotics (Risperdal, Seroquel, Zyprexa, Geodon, and Abilify) * Mood Stabilizers (Depakote, Lithium)

Answer 40

Bipolar Disorder

Question 41

What does the following describe? * A pattern of diminished sustained attention and increased impulsivity or hyperactivity * DSM-V Criteria * A persistent pattern of in (6+ of below for 6+mo to a degree that is different than developmental level: * Inattention: * Careless mistakes, Difficulty sustaining attention, Does not seem to listen, Does not follow through instructions, Difficulty in maintaining organization, Avoids tasks that need sustained mental effort, Loses things, Easily distracted, Often forgetful * Hyperactivity/ Impulsivity: * Fidgets, Leaves seat when expected to remain, Runs or climbs when inappropriate, Unable to engage in quiet play, “On the go” “Driven by a motor”, Talks Excessively, Blurts out answer, Difficulty waiting their turn, Often Interrupts. * Occurs before age 12 * Symptoms must be present in 2+ areas (School, Home, Grandparents house, Church, After School etc..) * Etiology * Definitely heritable, no clear genes * Looking into Dopamine because its used in the prefrontal cortex. Dysfunctional peripheral epinephrine may result in decreased production and CNS epinephrine activity. Stimulants effect both DA, and Adrenergic systems. * Decreased activity on PET in prefrontal cortexes. Higher rates in premature babies * Diagnosis * Direct Observation is best, teachers report is critical, there are standardised tests. * Prognosis: Persists through adolescence into adulthood in up to 60%. Higher risk of substance abuse, higher rates of anxiety and depression for being different * Treatment: Stimulants, Non Stimulants (atomoxetine SNRI), Alpha-Agonists, Bupropion (help to treat w/out increasing rish of substance abuse)

Answer 41

Attention Deficit Hyperactivity Disorder

Question 42

What does the following point to? * Significant Public Health Concern * Most don’t attempt nor contemplate suicide. * Etiology * Genetics: 40-50% heritability, Serotonin Transporter (5-HTTLPR), along with triggering event * HPA Axis, HPThyroid Axis, HPGonadal Axis. * Increased CORT, decreased FreeT4, * MRI differences, nothing diagnostic * Clinical Features * Onset can often be insidious: years of difficulty with hyperactivity, Separation anxiety, intermittent depressive symptoms * 5 of SIG-E-CAPS, must include low mood or anhedonia * Bereavement is within 2mo of the loss of a loved one unless also with worthlessness, SI, psychosis, or psychomotor retardation * Pre-Pubertal: somatic complaints, psychomotor agitation, mood congruent “hallucinations”, anhedonia, may say they’re MAD not SAD (cant say how they are feeling) * Adolescence: negativistic or antisocial behaviour, feelings of restlessness, irritability, aggression, withdrawal, less attentive with personal appearance * Differential includes: Dysthymia, Cyclothymic Disorder, Bereavement * Treatment: * CBT, Interpersonal Therapy, SSRIs (Prozac, Lexapro) * Black Box Warning can cause suicidal ideation right after starting * Treat for at least 1yr effective and decreases its prevelance

Answer 42

Depression

Question 43

What is this referring to? * Third Leading Cause of Death in Adolescents. * Young Children are incapable of designing and carrying out a suicide plan. * Children may state that they wish they were dead, or that they no longer want to feel how they feel. * SI is not fixed. * Methods: * Firearms\> Hanging\> OD (girls), Carbon Monoxide (Boys)

Answer 43

Adolescent Suicide

Question 44

What does this information pertain to? * THE MOST COMMON DISORDERS IN YOUTH * Separation ____ Disorder * It is a normal developmental phenomenon. Peaks between 9-18mo, diminishes by 2.5yrs. * Generalized ____ Disorder * Distress in Daily Activities in life, fear in multiple settings, expect negative outcomes * Restlessness, easily fatigues, mind going blank, irritability, muscle tension, sleep disturbance. * Also get autonomic arousal. Thoughts regarding HPA Axis here being overactive too! * Social ____ DO * Intense discomfort and distress in social situations, fear of scrutiny. * Crying, tantrums, freezing or becoming mute. * Treat with CBT and SSRIs * Selective Mutism- kids who can talk, but don't. Initially normal but should stop by school.

Answer 44

Anxiety

Question 45

What does the following point to? * 80% of people are exposed to one traumatic event in life, 10% develop \_\_\_\_ * Peak in exposure between age 16-20. * Etiology * Biological : pre-existing depression/anxiety with externalizing behaviours at age \<6yo * HPA axis hyperactive, increases a developmental exposure to NE, E, DA, CORT, etc.. * Psychological- Operant Conditioning, and modelling * Dx and Clinical Features * Most common exposure is Physical/Sexual Abuse, Domestic/School/Community Violence, Being kidnapped, MVA, accidents * Intrusive memories, scary dreams, dissociative reactions, and intense psychological duress * RE-EXPIRENCING, AVOIDANCE, * Negative alterations in cognitions * \<6yrs: withdrawn behaviour, reduced expression of positive emotions, decreased interest in play, feelings of shame, confusion * 6+yrs: Psychological Amnesia * Negative self esteem, horror, anger, guilt, shame, psychological numbing * Hyperarousal: difficulty falling/staying asleep, vigilant regarding safety/checking * Course/Prognosis * Can spontaneously remit, often doesn't. Childhood ___ is often complicated with attachment issues and misdiagnoses * Treatment: * THERAPY: Trauma Focused CBT, Crisis Debriefing * MEDS: SSRIs (not better than placebo), Alpha-blockers (Clonidine, guanfacine, Prazosin)-fixes nightmares, Beta-Blockers- to help disrupt memory.

Answer 45

PTSD

Question 46

What does this refer to? * Reasonable risk taking is normal in adolescence * Alcohol: average age to first drink is 11, regular drinking by age 16, 18-25 binge drinking. * Tobacco: Was trending down, now e-cig and flavoured vapes are increasing nicotine use * Cannabis: most popular illicit drug. Can be easier to acquire than tobacco or alcohol. * Cocaine: 13% of high school seniors use cocaine * Opioids/Heroin: increasing use of pharmaceuticals, heroin/fentanyl is cheaper. Teens tend to use intranasal. * Hallucinogens, stimulants, etc.: all available to most varying to low rates of regular use. * Asking about substance use, start early! Normalize this question: * Establish familiarity and assess knowledge base * Ask about what friends are using, other kids at school. * Talk about risks of substance use: not just addiction, death, but other health consequences (teeth gross) * Gauge risk factors and establish what parents/guardians know and should know * Consider confidentiality

Answer 46

Adolescent Drug Use

Question 47

What do each of these terms mean? Behavior Dependence Physical Dependence Abuse Addiction

Answer 47

* Behavioral dependence * The repeated use of a drug or chemical substance * Physical dependence * Altered physiological state caused by repeated administration of a drug * Abuse * Use of any drug in a manner that deviates from approved social or medical patterns * Addiction * The repeated and increased use of a substance, the deprivation of which gives rise to symptoms of distress and an irresistible urge to use the agent again and which leads also to physical and mental deterioration (compulsive drug use despite harmful consequences)

Question 48

What is the difference between dependence and addiction?

Answer 48

* Addiction: the inability to stop using a drug; failure to meet work, social, or family obligations; and, sometimes (depending on the drug), tolerance and withdrawal * Physical dependence in and of itself does not constitute addiction, but it often accompanies addiction

Question 49

What is the epidemiology of Substance Use, Abuse and Addiction?

Answer 49

* High levels of substance abuse and dependence in the U.S. * \> 22 million individuals older than age 12 are classified with substance-related disorder (10% of the population) * Of this group, about 15 million with alcohol abuse/dependence * Abuse of tobacco, alcohol, and illicit drugs costs more than $740 billion annually related to crime, lost work productivity, and health care * Major cause of family dysfunction, work-related and non-work related accidents, relationship problems * Associated with crime, including violent crime * People who use drugs at an earlier age (14 or younger) are more likely to become addicted – most notably with alcohol * Demographics: * Males are more likely to be substance users * Native Americans/Alaska natives have the highest lifetime rate * West/Midwest \> Northeast/South

Question 50

What is the etiology of Substance Use, Abuse and Addiction?

Answer 50

Combination of genetics and environment Family studies suggest that 40-60% of an individual’s risk comes from their genetic makeup

Question 51

What are the Substance Use Risk Factors?

Answer 51

Question 52

What is the neurobiology of substance use and abuse? What is it considered a disease of? How does affect us?

Answer 52

* Substance use disorders are NOT disorders of self-control (initial choice is based on impulse control) * Considered a brain disease – drugs change the structure and function of the brain * Changes to prefrontal cortex seen – particularly damaging in adolescents where prefrontal cortex is still maturing! Changes to the prefrontal cortex affect executive function, attention, and memory * Short term memory loss * Impaired abstraction * Loss of impulse control * Impaired decision making ability * Personality changes * Increased dopamine activates the reward circuit * Drugs can release 2-10x more dopamine than eating or sex, which can occur immediately via injecting or inhaling * With long term substance abuse, the brain adjusts to exogenous dopamine flooding by reducing endogenous dopamine (downregulation) * Causes continued use of drugs in an attempt to normalize dopamine levels

Question 53

What is the comorbidity of substance abuse and addiction?

Answer 53

* Up to 50% of individuals with substance use disorders have comorbid psychiatric disorders * Bipolar disorder has the highest rate of co-occurring substance use disorders (excluding tobacco) * Depression is also common – think dopamine depletion * 20x more likely to commit suicide

Question 54

Given the DSM-5 Criteria, what are we talking about here? Characterized by: * 1. Impaired control * Using more drugs, cravings, spending high amounts of time * 2. Social impairment * Impaired relationships, not functioning at school/work/home * 3. Risky use * Failure to abstain despite physical sequelae (ex – IV heroin + endocarditis) * 4. Pharmacological criteria * Tolerance/withdrawal

Answer 54

Substance Use Disorders

Question 55

What are the classifications of Substance Use Disorders?

Answer 55

* Alcohol * Sedative-Hypnotics/Anxiolytics (benzodiazepines) * Stimulants (methamphetamine, cocaine) * Opioids * Cannabis * Hallucinogens (mushrooms, LSD) * Inhalants (solvents, propellants, fuels) * Anabolic-androgenic steroids * Tobacco

Question 56

Name the type of Substance Use Disorder we are referring to * Most common substance use disorder * 2 million injuries per year in the US, including 22,000 deaths * \> 15 million Americans * ____ is a GABA agonist * GABA = inhibitory neurotransmitter * Withdrawal can be fatal * Tremors can quickly progress to seizures, delirium tremens

Answer 56

Alcohol

Question 57

Explain the timing of Alcohol Withdrawal Symptoms

Answer 57

Question 58

How does one treat alcohol widthdrawal?

Answer 58

* Benzodiazepines are used to control psychomotor agitation and prevent progression of withdrawal symptoms * Benzos also enhance GABA, so a taper helps to bring levels back to normal * Also why you should not prescribe BZDs to a person with alcohol use disorder – increases chances of relapse * Typically lorazepam (Ativan) or diazepam (Valium) * Ativan is preferred for patients with liver damage – not metabolized by liver * Lorazepam * Oxazepam * Temazepam

Question 59

What is CIWA protocl for alcohol withdrawal?

Answer 59

Question 60

What is/are Delirium Tremens?

Answer 60

* Autonomic instability * Tachycardia * Hypertension * Hyperthermia * Diaphoresis * Agitation, disorientation, hallucinations * Aggressive treatment with high dose benzos * Mortality rate of up to 5% even w/ treatment, can be substantially higher if untreated

Question 61

These guidelines are a treatment procedure for what condition? * Naltrexone – ____ dependence, opioid addiction * Blocks mu-opioid receptor; helps to modulate the expression of \_\_\_\_'s reinforcing effects – reduces cravings * Cannot be given to patients taking opioids – induces withdrawal * Contraindications: acute hepatitis, liver failure * Naltrexone depot (Vivitrol) * Monthly injection

Answer 61

Alcohol Substance Dependence

Question 62

What are the consequences of Alcohol Abuse?

Answer 62

* Cirrhosis * Pancreatitis * Wernicke’s encephalopathy * Caused by thiamine depletion (vitamin B1) * Triad: encephalopathy/delirium, gait ataxia, nystagmus * Reversible, treated with high dose IV thiamine * Korsakoff’s syndrome * Late manifestation of Wernicke’s * Memory impairments, amnesia, confabulation * Poor prognosis; recovery is rare

Question 63

What class/type of substance abuse are we referring to with these drugs? * Benzodiazepines- Ativan, clonopin… * About 15% of individuals in the US have had a benzodiazepine prescription * Flunitrazepam (Rohypnol) – not available in the US but used as a date-rape drug * Intoxication similar to alcohol, less euphoria * Withdrawal similar to alcohol (GABA) * Use CIWA protocol or benzo taper to safely withdraw * Antidote to overdose is flumazenil – though somewhat controversial; can induce seizures * Barbiturates * Powerful sedatives, phenobarbital indicated for epilepsy * Highly lethal with only ten times the normal dose producing coma and death – severe respiratory and cardiovascular depression * Withdrawal is dangerous; sudden death can occur * Barbiturate-like substances * Methaqualone (Quaalude) * Belief that it heightens the pleasure of sexual activity * Most OD fatalities occur when combined with alcohol * Neuropsychiatric complications are the hallmark of sedative-hypnotic abuse

Answer 63

Sedative-Hypnotics/Anxiolytics

Question 64

What class/type of substance abuse are we referring to with this drug? * Amphetamines * Meth, Adderall * Among the most widely used illicit substances * Used to increase performance and to induce a euphoric feeling * Can induce psychosis, hypertension * Methamphetamine = potent drug that can be snorted, smoked, or injected * High can last for up to 12 hours * Meth mites = tactile hallucinations, skin sores

Answer 64

Stimulants

Question 65

What class/type of substance abuse are we referring to with this drug? Cocaine * Powder derived from the coca plant * Most commonly snorted, can be used IV or smoked * Crack = high potency form of cocaine that is smoked * Euphoria – Agitation – Aggression – Paranoia * Patients often “crash” after use or binges * Risk of psychosis/permanent paranoia * Cerebrovascular complications: stroke, cardiomyopathy * Cerebral atrophy occurs with long term use * Detectible on drug screen within 48-72 hours

Answer 65

Stimulants

Question 66

What class/type of substance abuse are we referring to with this drug? Synthetic cathinones (bath salts) * Cathinone is found in the Khat plant * Marketed as cheaper alternatives to other stimulants * Can be swallowed, snorted, smoked, or injected * Effects: * paranoia—extreme and unreasonable distrust of others * hallucinations—experiencing sensations and images that seem real but are not * increased friendliness * increased sex drive * panic attacks * excited delirium—extreme agitation and violent behavior

Answer 66

Stimulants

Question 67

Given the information what class/type of substance abuse is this drug? * Legal and illegal forms * ___ abuse widespread * High tolerance – in some cases, a 100-fold increase in dose is required to produce the original effect * Respiratory symtpoms don’t change w/ addiction * 21-29% of patients prescribed ___ for chronic pain misuse them * 8-12% develop an opioid use disorder * An estimated 4-6% who misuse prescription ___ transition to heroin * About 80% of people who use heroin first misused prescription \_\_\_

Answer 67

Opioids

Question 68

What was the Opioid Crisis?

Answer 68

* 1990’s, pharma reassured the medical community that patients would not become addicted to prescription opioids * Prescribing rates increased * Lead to widespread misuse of prescription opioids before the highly addictive properties became clear * Overdose rates subsequently increased

Question 69

The following is associated with which form of substance abuse? (Name the drug class/type) * Method of use: oral, intranasal, IV (higher risk of medical complications) * Euphoric high more pronounced with IV use * The initial euphoria is followed by a period of sedation, “nodding off” * 10 bags = 1 bundle of heroin * Dirty needles * Medical complications of IV use * Endocarditis * HIV * Hepatitis

Answer 69

Opioids

Question 70

What do these overdose symptoms refer to? Which type of drug abuse? * Unresponsiveness, coma, slow respirations, hypothermia, hypotension, bradycardia * Triad: coma, pinpoint pupils, respiratory depression * Treated with naloxone (Narcan) – intranasal or IM

Answer 70

Opioids

Question 71

What do these withdrawal symptoms refer to? Which type of drug abuse? * Severe muscle cramps and bone aches, profuse diarrhea, abdominal cramps, rhinorrhea, lacrimation, piloerection, fever, pupillary dilation, hypertension, tachycardia, temperature dysregulation * Cold turkey * Very uncomfortable but typically not life-threatening * Treated symptomatically – can do Methadone or Suboxone taper

Answer 71

Opioids

Question 72

What is the Opioid-free treatment of Opioid Withdrawal?

Answer 72

Don't need to do if methodone

Question 73

With Opioid Substance Dependence, What is the Maintenance Treatment?

Answer 73

Methadone * Long acting opioid agonist – reduces cravings and euphoria * Monitored regularly Lethal overdose is possible * First line for opioid use disorder in pregnancy * Can only be prescribed by licensed treatment centers (methadone clinic) * Caution: QT prolongation Buprenorphine * Partial mu-opioid agonist; can be prescribed in office setting with special license * Sublingual * Buprenorphine/naloxone (Suboxone) * Naloxone = opioid antagonist – used to treat opioid overdose * Naloxone has little to no activity when administered sublingually but causes withdrawal when injected by individuals with physiologic dependence on opioids * Prevents abuse

Question 74

What is the name of the substance abuse drug are we referring to? * The most widely used illegal\* drug * Euphoria, motor impairments, cognitive impairments * 8-12 hours after using cannabis 🡪 impaired motor skills * Interfere with the operating motor vehicles/heavy machinery * Most common physical effects: dilation of the conjunctival blood vessels (red eye), mild tachycardia, increased appetite, dry mouth * Orthostatic hypotension at high doses * Long-term cannabis use is associated with cognitive impairment and amotivational syndrome

Answer 74

Cannabis

Question 75

What are we referring to with this information? * K2, spice * Users are typically young males in their 20s to 30s * ~3.7% of high school seniors in the US reported using synthetic cannabinoids in 2017 * Drop from 11% in 2012 * Greater potential for serious neuropsychiatric toxicity including hallucinations, delirium, and psychosis – prolonged * “Zombie” article posted on Sakai * Severe psychomotor agitation, seizures, and coma

Answer 75

Synthetic Cannabinoids

Question 76

What are Hallucinogens? Name the drugs and what they cause side effect wise

Answer 76

* Psilocybin (mushrooms), mescaline (peyote cactus) * LSD, ketamine, PCP (angel dust) * MDMA (ecstasy) is classified in the DSM-5 as a hallucinogen, but has a similar structure to amphetamines * Physiological changes: pupillary dilation, tachycardia, sweating, palpitations, blurring of vision, tremors, incoordination * Hallucinogen Persisting Perception Disorder = flashbacks of a hallucination * Can induce prolonged psychosis * Ketamine – being studied for treatment resistant depression

Question 77

Name the 4 inhalant types

Answer 77

* “Huffing” * (1) solvents for glues and adhesives; (2) propellants (aerosol paint sprays, hair sprays, and shaving cream); (3) thinners (paint products and correction fluids); and (4) fuels (gasoline, propane)

Question 78

What type of substance abuse are we referring to below? * Various degrees of ___ (muscle building) and ___ (masculinizing) effects * More common use in males seeking to gain increased muscle mass and strength, either for athletic purposes or to improve personal appearance * May initially induce euphoria and hyperactivity * Anger, arousal, irritability, hostility, anxiety, somatization, and depression (especially during times when not using) * Correlation between steroid abuse and violence (“roid rage”) * ___ abusers with no record of antisocial behavior or violence have committed murders and other violent crimes * Many adverse effects: hyperlipidemia, hypertension, MI, cardiomyopathy, stroke, testicular atrophy/sterility, acne, baldness

Answer 78

Anabolic-Androgenic Steroids

Question 79

The following describes what type of substance abuse? * ~50% of all psychiatric outpatients * ~70% of outpatients with bipolar I disorder * ~90% of outpatients with schizophrenia * ___ use is associated with ~400,000 premature deaths each year in the US—25% of all deaths * ___ acts as an agonist at the nicotinic subtype of acetylcholine receptors * ~25% of the ___ inhaled during smoking reaches the bloodstream 🡪 through which __ reaches the brain within 15 seconds * Activates dopamine reward system * Cardiovascular risks, cancer risks

Answer 79

Tobacco Use Disorder Nicotene acts as an agonist 25% of nicotene inhaled

Question 80

What are these withdrawal symptoms associated with? * Withdrawal symptoms can develop within 2 hours of smoking the last cigarette * Generally peak in the first 24 to 48 hours * Can last for weeks or months * Symptoms: * Intense craving for tobacco * Tension, irritability, difficulty concentrating * Drowsiness and paradoxical trouble sleeping * Decreased heart rate and blood pressure * Increased appetite and weight gain * Decreased motor performance * Increased muscle tension

Answer 80

Nicotine Withdrawal

Question 81

What are treatments (drugs) for Substence Dependence for Tobacco?

Answer 81

* Nicotine replacement therapy – gum, patch * Varenicline (Chantix) * Reduces the symptoms of nicotine withdrawal; also blocks the nicotine in tobacco smoke from binding to the receptor, reducing the rewarding aspects of cigarette smoking * Side effects: cardiovascular and neuropsychiatric – mood instability, suicidal ideation * Bupropion (Zyban, Wellbutrin SR) * Helps reduce cravings * Lowers seizure threshold

Question 82

What are the myths of substance abuse? (NIDA)

Answer 82

* Myth: Substance addiction is voluntary behavior * Initial choice is voluntary, but the neurobiological changes that occur are not * Myth: Substance addiction is a character flaw * It’s a brain disease * Myth: You have to want drug treatment for it to be effective * Many individuals benefit from court-mandated treatment or only going because a loved one urged them to * Myth: Treatment should be a “one-shot deal” * Chronic disorder, repeated treatment often needed, relapse is part of the process * Myth: We should strive to find a "magic bullet" to treat all forms of drug abuse * Treatment and services available should be tailored to meet the needs of each individual uniquely

Question 83

What is Gambling Disorder? What are some facts, side effects and so on?

Answer 83

4+ of the following in a 12-month period: * Needs to gamble with increasing amounts of money to achieve desired excitement * Irritability when attempting to cut down or stop gambling * Repeated unsuccessful efforts to control, cut back, or stop gambling * Preoccupied with gambling * Often gambles when feeling distressed (helpless, guilty, anxious, depressed) * After losing money gambling, often returns another day to get even * Lies to conceal the extent of involvement with gambling * Has jeopardized or lost a significant relationship, job, or educational or career opportunity because of gambling * Relies on others to provide money to relieve desperate financial situations caused by gambling

Question 84

Whom is Gambling Disorder more common with? How do you treat Gambling Disorder?

Answer 84

* More common in men and young adults * Women with gambling disorder tend to be older adults * 10-18% of patients with substance abuse are pathological gamblers * Many have underlying mood disorders * Treatment with psychotherapy * SSRIs and mood stabilizers have been used successfully – treating underlying comorbidities? * GA – gamblers anonymous

Question 85

What are the side effects for the following: Small doses High Doses Neurological symptoms Long Term use

Answer 85

Small initial doses: disinhibition, euphoria, excitement, floating sensation High doses: psychological symptoms of fearfulness, sensory illusions, auditory and visual hallucinations, and distortions of body size. Neurological symptoms can include slurred speech, decreased speed of talking, and ataxia Long-term use can be associated with irritability, emotional lability, and impaired memory