final - behavioral Flashcards
(36 cards)
feeding disorders: causes and why would a kid refuse to eat
causes:
-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 Stages
0–2 mo: Homeostasis (Establish basic physiologic regulation: sleep, hunger, digestion)
2–6 mo: Attachment (Feeding becomes a social-emotional experience)
6 mo–3 yrs: Separation & individualization (Child begins to assert independence and autonomy)
→ Dysfunctional feeding = disrupted parent-child dynamic
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 and prognosis
special consideration: low yield
-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 (ODD) **
know how to tell vs conduct
-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 **
whats the managment after therapy?
-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
🧠 Pediatric Anxiety: Stepwise Management
🥇 First-Line: Cognitive Behavioral Therapy (CBT)
Especially with exposure-based techniques
Teach child to recognize physical symptoms of anxiety
Identify maladaptive thoughts (“I’m going to fail”, “I can’t do this”)
Practice exposure to feared situations (gradual and supported)
Involve parents early (especially for younger kids)
🧗♂️ After Initiation of CBT — Next Steps
Step Purpose
Track progress Use symptom rating scales or behavior tracking
Increase exposure difficulty Progressively face more anxiety-provoking situations
Address comorbidities ADHD, depression, ASD — adjust therapy if needed
Maintenance therapy Prevent relapse; space out sessions over time
School support 504 plan or IEP for test anxiety, separation issues
💊 Second-Line: Medication
Use when:
CBT alone is insufficient
Anxiety is severe or disabling
Access to therapy is limited
✅ Preferred Meds: SSRIs
SSRI Notes
Sertraline Often used; well tolerated in children
Fluoxetine Also common; long half-life
Escitalopram Used, but less data in very young children
🧠 Not FDA-approved for anxiety in kids, but widely used off-label
Start low and titrate slowly
Monitor for activation, suicidal thoughts
🚫 Avoid (or use with caution)
Benzodiazepines: Discouraged — risk of dependence, disinhibition
Hydroxyzine, propranolol, clonidine: Can help with physical symptoms (e.g., test anxiety, sleep), but not first-line
📌 TL;DR
Start with CBT with exposure
Build confidence, identify triggers, teach coping
If still impaired → add SSRI
Avoid benzos
Support at home + school is essential
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
🟢 Mild Depression
Monitor closely over several weeks
Psychoeducation for child + caregivers
Encourage:
Sleep hygiene
Physical activity
Social engagement
Healthy routines
No meds initially — focus on behavioral activation
🟡 Moderate to Severe Depression
Requires active, multi-modal treatment:
🔹 Psychotherapy
CBT:
Helps restructure negative thoughts
Builds coping strategies
Encourages labeling and expressing emotions
IPT (Interpersonal Therapy):
Focuses on relationships, grief, transitions, role conflicts
Family involvement:
Improve communication
Address relational stressors
💊 Medication Indications
Symptoms are:
Moderate and persistent, or
Severe
Especially if:
High functional impairment
Psychotherapy alone isn’t enough
Family history of depression (↑ chance of med response)
✅ First-Line Antidepressants in Kids (FDA Approved)
Drug Age Range Notes
Fluoxetine ≥8 years Best studied, first choice
Escitalopram ≥12 years Also FDA-approved
Start low and go slow
Monitor for:
Suicidal thoughts
Behavioral activation
GI symptoms, sleep, mood swings
🔬 Evidence: TADS Trial
CBT + Fluoxetine = best outcomes in first 12 weeks
Monotherapy with either CBT or fluoxetine also helpful
🚨 Suicide Risk
Having a plan = most serious warning sign
Always screen for:
Suicidal ideation
Plan
Access to means
Past attempts or self-injury
🔒 TL;DR Summary
Mild: Monitor, educate, behavioral activation
Moderate–Severe: CBT ± fluoxetine
CBT + fluoxetine = best evidence
Watch closely for suicidality, especially after starting meds
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 -> having a plan is most serious
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 -> having a plan is most serious
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
suicide -> having a plan is most serious
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
