Lecture 11: Pediatric Substance Use

Question 1

Substance Abuse Diagnosis

Answer 1

1. maladaptive pattern os substance use leading to significant impairment or distress
   a. failure to fulfill obligations (work/school/home)
   b. recurrent substance-related legal problems
   c. continued use despite continuing social problems caused by use
   d. using when physically hazardous

Question 2

Diagnostic Testing Substance Use

Answer 2

1. self-report
2. lab testing
   - UDS
   - Blood
   - Breath
   - Hair
   - saliva
   - sweat

Question 3

Treatment Substance Use (6)

Answer 3

1. treatment intensity should reflect severity of d/o
2. often outpatient treatment
3. family therapy is most researched-most comprehensive
4. other psycollcial models
5. pharmacologic
6. relapse rates over 60% at 12 months after treatment

Question 4

Depressive D/O (8)

Answer 4

1. consistently sad or depressed
2. anhedonia
3. changes in appetite or sleep
4. irritability or agitation
5. fatigue
6. hopelessness/helplessness/worthlessness
7. poor concentration
8. SI

Question 5

DDX for Depressive D/O (5)

Answer 5

1. anxiety
2. untreated ADHD
3. substance use
4. bipolar
5. medical conditions

Question 6

Diagnosis and treatment depressive d/o (5)

Answer 6

1. full psych eval is most useful tool
2. mood and feeling questionnaire
3. tx approach varies with severity/duration/comorbidity
4. SSRIs
   - black box warning to increase suicide ideation in patients ages 24 and under
5. Psychotherapeutic interventions

Question 7

Separation Anxiety (6)

Answer 7

1. developmentally inappropriate and excessive anxiety regarding separation from home or parent/caregiver
2. 2%-4% of children and adolescents
3. accounts for 50% of all anxiety referrals at this age
4. linked to insecure attachments
5. may be precipitated by loss separation
   - actual or threatened
6. assoc. with parental anxiety and enmeshment
   -enmeshment=parental/caregiver boundaries blurred
   “icky” per lecturer

Question 8

Generalized anxiety d/o (5)*

Answer 8

1. excessive anxiety and worry most of the time for 6+ months causing significant distress and impairment in functioning
2. estimated 3% of children and 6%-7% adolescents
3. assoc. with familial anxiety d/o
4. also assoc. with parents who are anxious, hypercritical, have high expectations
5. can manifest as children asking a lot of questions

Question 9

Avoidant Personality d/o

Answer 9

1. pervasive social inhibition , a sense of inadequacy
   - hypersensitivity to criticsm
2. leads to avoidance of involvement, preoccupation with rejection and low self-esteem

Question 10

Social Phobia (6)

Answer 10

1. marked, persistent fear of situations that involve potential scrutiny
2. fear is severe enough to interfere with normal functioning
3. prevalence of avoidant PD and social phobia together
4. 9% or 1.1%
5. ratio to girls to boys is 7:3
6. often precipitated by traumatic event
7. strong familial basis

Question 11

Panic D/O

Answer 11

1. recurrent, unexplained panic attacks followed by 1+ month changes in bx related to the panic attack
2. can include agoraphobia
3. not due to a substance
4. base prevalence unknown
5. 1st degree relatives of people with panic d/o meet criteria in 20-40% cases

Question 12

Selective Mutism (6)

Answer 12

1. consistent failure to speak in specific social situations where there is an expectations of speaking despite speaking in other situations
2. interferes with educations/occupation
3. estimated prevalence 0.08%-0.7%
4. more girls and boys
5. 1-5 years AOO
6. manipulative, passive aggressive, reactive, phobic

Question 13

Differential DX anxiety D.o (4)

Answer 13

1. GI issues
2. Chronic illness
3. substance-induced anxiety
4. ADHD

Question 14

Diagnosis and Treatment Anxiety d/o

Answer 14

1. diagnosis by complete psych assessment
2. behavioral treatments
   - CBT
   - Desensitization
   - exposure
3. Pharmacologic
   - SSRIs
   - SNRIs
   - TCAs
   - Benzo

Question 15

Bipolar D/o (3)

Answer 15

1. variable clinical presentation
2. pediatric bipolar is mostly mild episodes, rapid cycling, or irritability
3. can be difficult to differentiate from ADHD and other psychiatric d/o

Question 16

Signs/Sx Bipolar D/O (8)

Answer 16

1. severe irritability
2. moodiness
3. temper tantrums
4. depression/anxiety
5. hyperactivity
6. increased self esteem
7. increased goal-directed behavior
8. psychosis

Question 17

Hypothesized contributors bipolar d/o (2)

Answer 17

1. biologic
   - correlations between genetic and neuroimaging findings
2. family environment
   - stress and abuse

Question 18

Differential DDX bipolar d.o (10)

Answer 18

1. ADHD
2. Schizophrenia
3. child-abuse
4. non-mood-related emotional and bx disturbances**
5. developmental delays
6. delirium
7. tumors
8. infections
9. seizure d/o
10. substance use

Question 19

Diagnostic testing bipolar d/o (4)

Answer 19

1. comprehensive history
2. consider developmental context
3. psych testing may be beneficial
4. possibly neuroimaging in the future

Question 20

Treatment Bipolar D/O (4)

Answer 20

1. mood stabilizers or atypical antipsychotics
2. official recommendation
   : lithium or depakote*
3. atypicals are very effective
4. psychotherapeutic interventions (CBT)
   * increased electrical activity, which also occurs in seizure d/o therefore, anticonvulsants can help

Question 21

Suicidal/Self-injurious behavior (4)

Answer 21

1. suicidal ideation vs. suicide attempt
2. non-suicidal self-injurious behavior
3. consider severity of ideation
4. consider lethality of attempt

Question 22

Epidemiology Suicidal/Self-injurious behavior (6)

Answer 22

1. completion rare in children 5-14 yr.
2. completed suicide in adolescents 15-19 years 3rd leading cause of mortality
3. females attempt 2x more
4. males complete 4x
5. underlying psych d/o
6. other rx

Question 23

Treatment Suicidal/Self-injurious behavior (4)

Answer 23

1. rx assessment
2. focus on underlying d/o
3. CBT or IPT
4. pharmacologic

Question 24

Child Maltreatment Dx

2
4 forms maltreatment

Answer 24

1. legal definitions vary by state
2. forms of maltreatment
   a. neglect
   - educational, physical, medical

b. physical abuse
c. sexual abuse
d. emotional abuse

Question 25

Epidemiology child maltreatment

Answer 25

1. 3 million CPS reports annually 2. 60% neglect - 20% physical abuse - 10% sexual 3. 1,500 children die every year related to maltreatment

Question 26

Factors assoc. with child maltreatment (4)**

Answer 26

1. poverty 2. financial stress 3. poor housing 4. social isolation

Question 27

Dx Child maltreatment (3)

Answer 27

1. interviews of child and patient 2. explore credibility 3. psych testing

Question 28

Treatment Child Maltreatment (3)

Answer 28

1. maintain safety 2. psychiatric tx for significant psych or bx symptoms 3. trauma-focused CBT

Question 29

PTSD Dx (8) Infants-School aged children

Answer 29

infants-schoolchildren present as behavioral changes 1. ease of feeding 2. sleeping 3. general settling 4. regressed behavior 5. unwillingness to explore 6. increased aggression 7. clinginess 8. increased stranger danger

Question 30

PTSD Dx Primary-High school children (8)

Answer 30

similar to adult symptoms 1. fear of death 2. separation anxiety 3. fear of the traumatic event 4. nightmares 5. sleep disturbances 6. flashbacks 7. fear of stimuli leading to event 8. hyperarousal

Question 31

DDX PTSD (2)

Answer 31

1. depression | 2. anxiety/ panic

Question 32

Diagnosis & treatment PTSD (5)

Answer 32

1. psych testing 2. history 3. SSRIs 4. Alpha agonists 5. psychological first aid * *Does not depend on the event itself, dependent on child's PERCEPTION of the event - 2 children can go through the same event: one can get PTSD while one cannot

Question 33

Tourette's Dx (5)

Answer 33

1. TIC: sudden rapid, recurrent, nonrhythmic, stereotyped, movement of vocalization 2. tics occur many times a day ( usually in bouts) nearly every day for more than 1 year 3. never tic free for more than 3 consecutive months 4. onset before age 18 5. not due to substance or medical condition

Question 34

Epidemilology/etiology Tourette's (7)

Answer 34

1. transient tics comon in school aged children 2. chronic motor tics 1/4 3. 2x likely in boys 4. seemingly strong heritability 5. stress-sensitive 6. increasingly aware of urges and exercise some control as they get older 7. evidence implicates basal ganglia and corticosteroid thalamocortical abnormalities

Question 35

DDX tourette's (3)

Answer 35

1. distinguish from movement d/o caused by medical conditions - MS, Head injury, huntington's 2. r/o PDD 3. r/o OCD 4. r/o extrapyramidal side effects from antipsychotics

Question 36

DX Tourette's (2)

Answer 36

1. clinical rating scales - Yale global tic severity scale - preferred for assessing initial severity and measuring changes 2. direct observation - most objective measure of severity

Question 37

Treatment Tourette's (8)

Answer 37

1. goal is to diminish sx, not eliminate 2. best to treat overall, long-term severity over exacerbation 3. treat comorbidities first 4. education and support 5. D2(dopamine) antagonists (atypical)*best 6. alpha agonists 7. habit reversal training 8. surgical intervention for adults with intractable tics (DBS)

Question 38

OCD DX (6)

Answer 38

1. obsessions 2. compulsions 3. time consuming and interfere with normal routine (1+ hour/day) 4. often kept hidden by children 5. in young children, parental observation of compulsive bx may be only definite sign of d/o 6. content of obsessions/compulsions is not due to another axis I dx

Question 39

Obsessions

Answer 39

intrusive thoughts, images, impulses that cause anxiety of distress

Question 40

Compulsions

Answer 40

repetitive behavioral or mental rituals that the person feels driven to perform due to the obsession

Question 41

epidemiology/etiology OCD (4)

Answer 41

1. adolescent prevalence between 1.9%-3.3% 2. seems to come from abnormalities of serotonin 3. some heritability 4. high prevalence of comorbidities

Question 42

DDX OCD (6)

Answer 42

1. MDD 2. GAD 3. body dysmorphia 4. specific phobia 5. hypochondria 6. autism/PDD

Question 43

Dx and treatment OCD (4)

Answer 43

1. observation 2. children's yale-brwon obsessive compulsive scale - CY-BOCS 3. CBT 4. SSRIs - fluoxetine - sertraline - fluvoxamine - paroxetine - citalopram

Question 44

Possible indicators of sexual abuse

Answer 44

1. bedwetting 2. accidents - check for patterns of accidents, or time frame where accidents are happening