final - behavioral Flashcards
(36 cards)
feeding disorders
-Fine motor skill deficits, oral-motor dysfunction (gagging, trouble chewing, and/or swallowing, aspiration), cardiopulmonary disorders leading to fatigue, GI disturbances causing pain/discomfort, neuromuscular conditions, social/emotional issues, problems w/ food regulation
-Infants/young children may refuse to eat if:
-Required NGT feedings/periods of fasting and IV nutrition in first 1-2 months of life
-Needs to burp more frequently or who needs time between bites, but instead is rushed
-They find eating painful/frightening: Esophageal atresia repair w/ stricture, oral candidiasis, history of choking
-Rhythm of feeding experience with the caregiver is not harmonious
-Forced to eat by maltreating parent/overzealous caregiver
-Food refusal may look like child outright refusing to eat, spitting out food, turning head away from food, verbally refusing
-Children w/ medical conditions or developmental disabilities more likely to experience feeding problems
feeding disorders: normal feeding stages
-0-2 months: Development of homeostasis
-Feeding accomplished most easily when parent allows infant to determine timing, amount, and pacing of food intake
-2-6 months: Attachment
-Allowing infant to control the feeding engages infant in a positive manner
-6 months to 3 years: Separation and individualization
-Vulnerable stage: Conflict arises if parent seeks to dominate child by intrusive and controlling feeding behavior at same time child is trying to achieve autonomy
-When disturbance occurs in the parent-child relationship at any of these stages, difficulty in feeding may ensue (both parent and child contributing to dysfunctional interaction)
feeding disorder: hx
-Elicit information concerning parents’ perception of child’s behavior and their expectations of the child, how often refusal is happening, if it happens w/ specific food/textures, specifics about the environment or setting in which the child eats, how the family manages food refusal, when challenges started, if any changes/stressors occurred
-What is the child eating throughout the day?
-Sneaking or consuming excessive liquids can decrease appetite at mealtime
-Question about discomfort/pain while feeding
-Dental pain > May have pain w/ foods that require use of dentition (chewy, crunchy foods)
-GI pain > Reflux, frequent vomiting, choking/gagging, dysphagia, constipation
feeding disorder: physical
-Oral-motor behavior and other clues suggesting neurologic, anatomic or physiologic abnormalities
-Emotional state and development level
-Depression or developmental delay?
-Feeding interaction should be observed live (if possible)
-Must help parents understand that infants and children may have different styles of eating and food preferences (olfactory, gustatory, tactile stimuli)
-When CC is failure to gain weight > DDX should also include medical disorders and maltreatment: MC cause is inadequate caloric intake
-Excessive weight loss: Excessive V/D, malabsorption
-More extensive work-up may be required, team approach may be necessary (CBC, ESR, UA/UCx, BUN/Cr, stool examination for fat/occult blood/O&P, LFTs/TFTs, swallowing functioning, GER evaluation
feeding disorders: management
-Goal is to identify contributing factors and overcome them
-Parents encouraged to view child’s behavior differently and try not to impose expectations and desires
-Establish a pattern of eating that’s harmonious w/ goals of family and caregivers
-Comprehensive diagnosis that considers all factors contributing to poor feeding
-Monitor feeding interaction and ensure appropriate weight gain
-Monitor developmental progress of child and the changes to the family dynamics that facilitate optimal weight gain and psychosocial development
-Provide support to the family as they seek to help the child
attention deficit/hyperactivity disorder dx
-Symptoms of ADHD fall into two categories: hyperactive/impulsive or inattentive (also a combined form)
-Significant impairment in attention or concentration and/or significant hyperactivity and impulsivity in excess of what is expected for age
-Functional impairment in at least two settings is required for diagnosis (parents and teachers for historians) – specialized forms exist for this
-Not all hyperactivity and/or inattention can be attributed to ADHD!
-Medical, psychiatric, learning, neurodevelopmental disorders may all present w/ symptoms suggestive of ADHD
ADHD tx
-Behavioral therapy is 1st line
-Stimulants are most effective and MC prescribed meds (75% of children experience sx improvement)
-Children who do not respond favorably to one stimulant may respond to a stimulant from other class (amphetamine versus methylphenidate)
-If stimulants not well-tolerated, non-stimulants may be used
-FDA approved: Atomoxetine, selective noradrenergic reuptake inhibitors, central a-adrenergic receptor agonists (guanfacine, clonidine) -> dont need to know
-External trigeminal nerve stimulation (ETNS): Device placed on forehead overnight to stimulate trigeminal nerve has FDA approval for those 7-12 years of age, not being treated w/ medication
-Effect is mild and did not separate from placebo until 4 weeks
-Side effects: Appetite increase, sleep difficulties, teeth clenching, headache, and fatigue
ADHD: special considerations w/ stimulant meds
-ADRs: Anorexia, wt loss, abdominal distress, headache, insomnia, dysphoria/tearfulness, irritability, lethargy, mild tachycardia, mild elevation in BP
-Less common SE: Interdose rebound of ADHD symptoms, anxiety, tachycardia, HTN, depression, mania, and psychotic symptoms
-Caution taken w/ cardiovascular hx, personal/family hx of drug abuse/addictive disorders (transdermal patches may be better)
-Use w/ caution in those w/ psychotic disorders and those w/ bipolar affective disorder (worsen symptoms)
-After initiating medications: Pulse, BP, height/weight recorded every 3-4 months and at times of dosage increases; also record abnormal movements (tics)
-Prognosis:
-60-85% of those diagnosed w/ ADHD in childhood continue to carry diagnosis into adolescence
-1/3rd of adults previously diagnosed w/ ADHD in childhood require ongoing medication management
oppositional defiant disorder (OOD)
-More common in families where caregiver, family-level, and/or environmental dysfunction (substance abuse, parental psychopathology, significant psychosocial stress) is present
-More prevalent in children w/ hx of multiple changes in primary caregivers, inconsistent/harsh/neglectful parenting, abuse, exposure to violence, or serious caregiver relational discord
-Dx: Usually evident < 8yo and may precede conduct disorder; symptoms first at home, then at school/peers
-Pattern of negativistic, hostile, and defiant behavior lasting at least 6 months
-Loses temper, argues w/ adults, defies rules
-Blames others for own mistakes and misbehavior
-Angry, easily annoyed, vindictive
-Does not meet criteria for conduct disorder
-Tx:
-Assessment of the psychosocial situation and recommendations to support parenting skills and optimal caregiver functioning
-Assessment for comorbid psychiatric diagnoses: Learning disabilities, depression, and ADHD (w/ appropriate interventions recommended)
conduct disorder
- -approx 9% of males and 2% of females <18yo
-Overlap w/ ADHD, substance abuse, learning disabilities, neuropsychiatric disorders, mood disorders, and family dysfunction
-RF: homes with domestic violence, child abuse, drug abuse, shifting parental figures, and poverty
-Hx of reactive attachment disorder
-Inconsistent and severe parental disciplinary techniques, parental alcoholism, and parental antisocial behavior
-Dx:
-Prototypical is boy w/ turbulent home life and academic difficulties
-Hyperactive, aggressive, and uncooperative behavior patterns in preschool/early school years tend to predict conduct disorder in adolescence w/ high accuracy
-Defiance of authority, fighting, tantrums, running away, school failure, and destruction of property
-With increasing age: Fire-setting, theft, truancy, vandalism, and substance abuse; sexual promiscuity, sexual perpetration, and other criminal behaviors may develop as well
-Tx:
-Multisystemic therapy (MST)- Intensive home-based model of care that seeks to stabilize and improve the home environment and strengthen the support system/coping skills of individual and family
-Identification of learning disabilities and placement in optimal school environment
-Addressing assoc neurologic and psychiatric disorders
-Early involvement in programs (Big Brothers, Big Sisters, scouts, team sports) in which consistent adult mentors and role models interact w/ youth
-Involvement of juvenile system in cases where behaviors lead to illegal activities, theft, or assault
-Prognosis:
-Generally worse if disorder presents <10yo, antisocial behaviors across multiple settings, pts raised in environments w/ antisocial behaviors of parent
-50% develop antisocial personality disorder as adults
autism spectrum disorder
-Neurologic disorder characterized by:
-Persistent deficits in social communication and social interaction across multiple contexts
-Restricted, repetitive patterns of behavior, interests, or activities
-DSM-5 combines autism, pervasive developmental disorder not otherwise specified, and Asperger syndrome into ASD
-Diagnostic Criteria
-Features typically present prior to 3 years of age (some not until later when social demands become greater)
-Features must cause “clinically significant impairment” in function relative to individual’s “general developmental level”
-Severity specified as level I, II, III based on how much support is needed
-Common -> 1 in 54 children
-4:1 male to female ratio
-~31% of children with ASD also have an intellectual disability
-Rare, pathogenic genetic variant detected in 10-30% of patients
-Strong familial component
autism spectrum disorder: Eval
-often not dx until 3-4yo, though atypical communication and behavior can be recognized in first 12-18mo
-MC early finding (12-18 months): Consistent failure to orient to one’s name, regard people directly, use gestures, and to develop speech
-Mounting evidence that dx can be made reliably by 14 months
-Evidence that diagnosis made at 14-18mo is stable at 3yo and early intervention is important -> multiple screening tools (for parents and clinicians)
-When behaviors raising concern for ASD are noted:
-Referral to team of specialists
-Referral to early intervention program and to a speech and language pathologist
-Testing:
-First-tier: Audiology evaluation, chromosomal microarray/DNA for fragile X syndrome
-Second-tier: Whole exome sequencing, whole genome sequencing, autism gene panels
-Metabolic screening, lead level, TFTs
autism spectrum disorder: management
-Early, intensive (up to 25 hours/week) behavior intervention is essential for cognitive/adaptive function
-Training models implemented before age 3 result in 90% of children attaining functional use of language compared to 20% who begin intervention after age 5
-Interventions should include parent training/involvement in treatment, ongoing assessment, program evaluation, and programmatic adjustment as needed
-Other interventions focus on communication, social interaction, and play skills that can be generalized in a naturalistic setting
-PCP should address medical concerns such as sleep problems, feeding problems w/ limited diet, constipation w/ withholding, and seizures
-Psychiatric comorbidities (anxiety/ADHD) also common
-Moderate efficacy of CBT for anxiety and/or SSRIs
-Irritability/aggression: Risperidone and aripiprazole FDA-approved
-Complementary tx: Special diets/supplements (limited evidence for efficacy)
anxiety disorders
-anticipation of future threat; fear is the emotional response to real/perceived imminent threat
-Both protective emotions, part of normal repertoire of children
-Fears/anxiety that persist beyond the expected developmental period or cause significant distress or impairment in functioning suggest an anxiety disorder
-Anxious temperaments can be identified as early as infancy -> more likely to develop anxiety disorders (especially if living w/ anxious parents)
-10% of children have some type of anxiety disorder (increasing in past decade)
anxiety: dx
-Children w/ anxiety are more likely to present with a physical complaint (headaches, abdominal pain) than with identified anxiety
-Screening should assess for other concomitant psychiatric disorders (depression), medications/substances that can cause anxiety/present similarly (caffeine, marijuana, amphetamines, cocaine, and alcohol during withdrawal), medical illnesses (hyperthyroid, hypoglycemia, hypoxia, pheochromocytoma)
anxiety tx
-Younger children: Helping parents understand child’s symptoms, developing skills to manage distress, helping parents tolerate their child’s distress
-As soon as they have developmental capacity to assess their own anxiety/learn coping strategies, child is incorporated into therapy
-First-line is cognitive behavioral therapy (CBT) w/ exposure
-Exposure refers to planned progressive presentation of low- to mid-level anxiety-provoking stimulus
-Aim is to desensitize the child to the stimulus
-Basic goals: Help child identify/quantify anxiety symptoms, identify maladaptive cognitions, learn cognitive/behavioral coping strategies to begin exposures
-Ultimate goal: Enable child to face specific anxiety or set of anxieties that cause distress/dysfunction, experience decrease in anxiety, and resume normal functioning
-Second-line: Psychopharmacologic agents
-Selective serotonin reuptake inhibitors effective in treating anxiety disorders in children as young as 6 years of age – not FDA approved, however
-Use of benzodiazepines while waiting for the anxiolytic effects of SSRIs is discouraged w/ youth
-Antihistamines (hydroxyzine), B-blockers, and a-agonists are alternatives that can be used on scheduled or as needed basis
anxiety: prognosis
-Early tx can be very effective and decreases risk for negative impact on developmental trajectories or development of other psychiatric disorders
-SOC: CBT for milder cases and combination of CBT/antidepressant for more severe cases
-Those with more severe symptoms often develop several anxiety disorders during adolescence and are at risk for depression, substance abuse, and other negative developmental outcomes
-Parenting style should be evaluated, parents should be treated for anxiety disorders to improve child’s outcome
depression: general considerations
-depression in children increases with age
-1-3% prior to puberty, 9% for adolescents, 20% over course of adolescence
-Sex incidence is equal in childhood, but with onset of puberty, females > males
-Rate of depression in females approaches adult levels by age 15
-Incidence in children higher when other family members have been affected by depressive disorders
-Lifetime risk of depression ranges from 10-25% for women and 5-12% for men
depression: dx
-persistent state of unhappiness or misery that interferes w/ pleasure or productivity
-Children/younger adolescents more likely to present with an irritable mood state; adolescents more likely a sad mood
-May start to make comments: “I have no friends,” “life is boring,” “there is nothing I can do to make things better,” “I wish I were dead”
-Behavioral patterns: Social isolation, deterioration in schoolwork, loss of interest in usual activities, anger, irritability
-Sleep and appetite patterns change: Tiredness, headaches, stomach aches, MSK pains
-Identified by asking about symptoms (easier with adolescents)
-Several symptoms cluster together over time, persist for > 2 weeks, and cause impairment > major depressive disorder may be present
-Depressive symptoms are of lesser severity, persist for > 1 year: Dysthymic disorder
-Milder symptoms in response to some stressful life event: Adjustment disorder w/ depressed mood
-AAP recommends annual screening for depression in children aged 12 and older using standardized measure
-Patient Health Questionnaire-9 modified for teens (PHQ-9A)
depression: tx
-Mild depression:
-Close monitoring over several weeks and psychoeducation that includes caregivers
-Tx team may be able to identify targets for change (lifestyle changes) that may improve depression
-Moderate-severe depression
-Comprehensive plan to tx depressive episode, help family respond effectively to pt’s emotional needs, and build supports within the school setting if needed
-Consider referrals for patient and possibly adjunctive family therapy
-CBT and interpersonal therapy (IPT) both have evidence for improving depressive symptoms in children and adolescents
-CBT focuses on building coping skills to change negative thought patterns that predominate in depressive conditions
-CBT also helps identify, label, and verbalize feelings and misperceptions
-In therapy, efforts made to resolve conflicts between family members and improve communication skills w/in family
-When sx are moderate and persistent or severe -> antidepressant meds may be indicated
-Positive family hx of depression increases risk of early-onset depression in children and adolescents and the chances of a positive response to antidepressant medication
-Tx of Adolescent Depression Study (TADS) found that CBT + fluoxetine led to best outcomes in tx of pediatric depression during first 12wks of tx
-Important to monitor target sx and document responses about suicidal thinking and self-injurious behaviors
-Depression in toddlers and young children best approached with parent-child relational therapies
-only fluoxetine and escitalopram are FDA approved for kids
depression: other considerations and prognosis
-Other Considerations
-Risk of suicide is the most significant side effect associated w/ depressive episodes
-Adolescents w/ depression are at higher risk for substance abuse and engaging in self-injurious behaviors (cutting, burning w/o suicidal intent)
-School performance usually suffers (unable to concentrate, motivate)
-Loss of peer relationships, tension w/ family
-Depression can coexist w/ other mental illnesses, medical illness (hypothyroid)
-All should be asked about suicidal ideation, physical/sexual abuse, and substance abuse
-Prognosis
-Comprehensive treatment intervention, including psychoeducation for the family, individual and family psychotherapy, medication assessment, and evaluation of school/home environments often leads to complete remission of depressive symptoms over a 1- to 2-month period
-Medications should be continued 6-12 months after remission of symptoms to prevent relapse
suicide risk in children/adolescents
-a worsening public health concern
-increased 57.4% between 2007-2018 -> 2nd leading cause of death in 10-24yo in U.S.
-Attempts > suicide (50-100:1)
-Adolescent girls- 3-4 x as many attempts as boys of same age
-deaths by suicide is 3-4 x greater in boys
-Firearms > suffocation > poisoning
-Different populations experience different risk factors and disparities, including access to appropriate healthcare
-American Indian youth have highest suicide rates among ethnic groups
-Black youth suicide rates have increased faster than any other group
-Increased rates for female Hispanic youth
-Increased risk for Gender Diverse youth and youth with non-heterosexual orientations, especially in non-supportive environments
-Risk w/ psychiatric disorders: Depression, bipolar disorder, psychotic disorders, substance use disorders, PTSD, panic attacks, and conduct disorder
-Risk w/ behaviors: Aggression, sleep difficulties, irritability, intoxication at time of attempt, history of previous suicide attempts or of non-suicidal self-injury
-Exposure through media/social media have also been associated w/ increased risk
-Other risks outside of youth’s control: History of trauma, adoption, loss, familial suicide, parental mental health problems
-Most young people who attempt suicide provide some indication of their distress or their tentative plans/show signs of dysphoric mood
-On screening, over 60% make comments such as “I wish I were dead” or “I just can’t deal with this any longer”
-Nearly 70% of subjects experienced a crisis event (loss, public shaming, failure, or and arrest) prior to dying by suicide
-Protective factors: Health connections to peers, supported engagement in communities (school, athletics, employment, religious/cultural activities), supportive family relationships; skills such as problem solving, emotional regulation, and support seeking
suicide risk: assessment
-Assessment of Suicide Risk:
-Routine screening for children 12 and older
-If suicidal thinking expressed, assess for: Presence of active plan, intent to carry out plan, access to lethal means, history of prior suicide attempts
-Suicidal ideation accompanied by any plan warrants immediate referral for a psychiatric crisis assessment (ED)!
-Immediate Steps When Risk is Suspected
-Do not leave patient alone
-Provider should meet with the patient and the family (alone and together), stating that solutions can be found w/ assistance of mental health professionals
-Err on side of caution in deciding whether further referral or an emergency evaluation is indicated
-Prevention
-Heightened awareness in the community and schools to identify at-risk individuals and increased access to services (hotlines, culturally appropriate counseling services)
-Restricting access to firearms (85% of deaths due to suicide or homicide in U.S.)
-Instructing families to lock medications, removing access to sharp objects, and ensuring that other common mechanisms are not accessible
sexual and gender identity: sexual orientation
-Pattern of physical and emotional arousal toward another person -Emerges before or early in adolescence -Though many have sexual experiences with a same-sex partner, fewer will affirm LGBTQ orientation by late adolescence -By 18 years of age, most individuals endorse certainty around sexual orientation -Important to use gender-neutral terms to promote environment of inclusivity and counsel based on sexual behavior, not solely orientation -LGBTQ children face stigmatization from homophobia/heterosexism, ostracism, and family rejection -Higher rates of social isolation, verbal harassment, and physical assault -Educational and unbiased LGBTQ information not always available in schools/community settings -High risk of negative self-esteem, mental health issues, substance abuse, and sexual risk-taking behaviors ->2X as likely to report considering suicide than their heterosexual peers -Significant health disparities for sexual minority youth related to sexual health outcomes -Clinicians should provide reassurance to parents feeling guilt/shame
