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Flashcards in Pediatric Psych Deck (85):
1

Manifestations of ADHD

Hyperactivity
Impulsivity
Inattention

2

Symptoms of ADHD

Cognitive functioning
Academic functioning
Behavioral functioning
Emotional functioning
Social functioning

3

Hyperactive ADHD Male to Female Ratio

4:1

4

Inattentive ADHD Male to Female Ratio

2:1

5

Comorbid Disorders of ADHD

Oppositional defiant disorder
Conduct disorder
Depression
Anxiety disorder
Learning disabilities

6

Pathogenesis of ADHD

Genetic imbalance of catecholamine metabolism in cerebral cortex
Environmental factors

7

Cerebral & Functional Abnormalities in ADHD Result in

Impaired executive functions
Impulsivity

8

Impaired Executive Functions in ADHD

Forward planning
Abstract reasoning
Mental flexibility
Working memory

9

Dietary influences on ADHD

Food additives
Refine sugar intake
Food sensitivity
Essential fatty acid deficiency
Iron & zinc deficiency

10

Associations with ADHD

Prenatal exposure to tobacco
Prematurity
Low birth weight
Prenatal exposure to alcohol
Head trauma in young children

11

Symptoms of ADHD

Inattentiveness
Impulsivity
Hyperactivity

12

Diagnosis of ADHD

Persistence, pervasiveness, and functional complications of the behavioral symptoms

13

Criteria for ADHD

Present in more than one setting
Persist for 6+ months
Present before age 12
Impair function in academic, social, or occupational activities
Excessive for developmental level of the child
Other mental disorders

14

Symptoms of Hyperactivity ADHD

Excessive Fidgetiness
Difficulty remaining seated when sitting is required
Feelings of restlessness or inappropriate running around or climbing
Difficulty playing quietly
Difficult to keep up with

15

Symptoms of Impulsivity ADHD

Excessive talking
Difficulty waiting turns
Blurting out answers too quickly
Interruption or intrusion of others

16

When are hyperactive ADHD symptoms typically observed?

By the time child reaches 4
Increase up to 7-8
After 8, symptoms decline
Adolescent- may not be noticeable

17

When are impulsive ADHD symptoms usually observed?

Persist throughout life

18

Symptoms of Inattention ADHD

Failure to provide close attention to detail, careless mistakes
Difficulty maintaining attention in play, school, or home activities
Seems not to listen, even when addressed
Fails to follow through
Difficulty organizing tasks, activities, & belongings
Avoids tasks that require mental effort
Loses objects required for tasks or activities
Easily distracted by irrelevant stimuli
Forgetfulness in routine activities

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Description of the Inattentive Subtype of ADHD

Sluggish cognitive tempo and frequently appear to be daydreaming or "off task"

20

ADHD Symptoms Impair Function in 3 Areas

Academic
Social
Occupational

21

Evaluation of a Child with ADHD

Medical
Developmental
Educational
Psychosocial evaluation

22

Medical Evaluation of ADHD

School- learning, happy, behavioral problems, completing assignments
Prenatal exposures
Perinatal complications or infections
CNS infection
Head trauma
Recurrent OM
Meds
Family Hx of similar behaviors

23

PE of ADHD Children

Measurements
Dysmorphic features
Neurocutaneous abnormalities
Neuro exam
Observation of behavior

24

Developmental & Behavioral Assessment of ADHD child

Onset, course, functional impact
Emotional, medical,& developmental events
Developmental milestones
School abscess
Psychosocial stressors
Observation of parent-child interactions

25

Narrow Band Scales for ADHD

Establish presence of core symptoms
Depends on age of child, scale used, & informant

26

Broadband Scales Assess What for ADHD

Internalizing behaviors
Externalizing behaviors other than ADHD
Identify coexisting condition & narrow DDx

27

Educational Evaluation of ADHD

Teacher completes ADHD specific rating scale
Narrative summary of classroom behavior & interventions, learning patterns, & functional impairment
Copies of report cards & schoolwork
Review multidisciplinary evals

28

DSM-5 Criteria for ADHD

6+ symptoms of hyperactivity & impulsivity OR inattention
17+ years is 5+ symptoms of hyperactivity & impulsivity OR inattention

29

Hyperactivity/Impulsivity or inattention must do what according DSM-5 criteria?

Occur often
Present in 2+ settings
Persist for 6+ months
Present before 12 years
Impair function in academic, social, or occupational activities
Be excessive

30

3 Subtypes of ADHD

Predominantly inattentivie
Predominantly hyperactive-impulse
Combined

31

Treatment of ADHD

Behavioral interventions
Medication
School-based interventions
Psychological interventions alone or in combination

32

Treatment goals of ADHD

Improved relationships with parents, teachers, siblings, or peers
Improved academic performance
Improved rule following

33

Indications for ADHD Referral

Coexisting psychiatric conditions
Coexisting neurologic or medical conditions
Lack of response to controlled trial of stimulant therapy or atomoxetine

34

Who to Refer ADHD Patients to?

Developmental behavioral pediatrician
Child neurologist
Psychopharmacologist
Child psychiatrist
Clinical child psychologist

35

Criteria for Initiation of Pharmacotherapy in Children with ADHD

Confirmation of ADHD
6+ years
Parents approval
School cooperation
No sensitivity to med
Normal HR & BP
Seizure free
Not have Tourette syndrome
Not have pervasive developmental delay
Not have significant anxiety
Substance abuse not a concern

36

Medical Therapy for ADHD

Dextroamphetamine (S)
Methylphenidate (S)
Atomoxetine (Strattera) [NS}
Buproprion (Wellbutrin) [NS]
TCAs [NS]
SSRIs [NS]
MAOIs [NS]
Alpha adrenergic agonists [NS]

37

Pretreatment work-up for ADHD

Comprehensive, CV focused patient hx, family hx, and PE
Vitals & assess growth
Pretreatment baseline for SE
Substance use/abuse
Prescribed to help with self-control & ability to focus
Review risks & benefits
Explanation of process & length of time
Frequency of follow-up
Information needed at follow up appt.
Behaviors/SE that family should monitor

38

First Line Stimulant Agents for ADHD

Ritalin
Methylin
Ritalin SR
Metadate ER
Methylin ER
Ritalin LA
Metadate CD
Concerta
Daytrana
Dextrostate
Dexedrine
Spansule
Adderall
Adderall XR
Focalin

39

Second Line Stimulant Agent for ADHD

Atomoxetine (Strattera)

40

Third Line Stimulant Agents for ADHD

Bupropion (Wellbutrin)
Imipramine (Tofranil)
Desipramine (Norpramin)
Clonidine (Catapres)
Guanfacine (Tenex)

41

Medication Management of ADHD

Start with short acting
Start low & titrate up
"Drug holidays"

42

ADHD Medication Black Box Warning for Stimulants

Increased risk of sudden death
CV problems
Drug dependency

43

ADHD Medication SE

Appetite suppression
Abdominal pain
Headache
Insomnia
Irritability
Tics
Associated with growth delay

44

Medication for Preschool Children with ADHD

Methylphenidate

45

3 Types of Autism Spectrum Disorders

Autistic disorder
Asperger syndrome
Pervasive developmental disorder not otherwise specified

46

Prevalence of Autism Spectrum Disorders

1:88 US children
Male > Female

47

Etiology of Autism Spectrum Disorders

Secondary to environmental, biologic, and genetic factors
Prenatal exposure to Valproic acid or thalidomide
Prematurity or low birth weight
Born to older parents
Co-occurs with other developmental, psychiatric, neurologic, chromosomal & genetic diagnosis

48

3 Main Areas of Function Affected by Autism Spectrum Disorders

Social interaction
Communication
Behaviors & interests

49

Autistic Behavior

Development delayed from birth
Sudden loss of social or language skills after normal development

50

Asperger's Syndrome

Mildest form of autism
Boys > Girls 3:1
Interested in single object/topic
Impaired social interaction
Normal to above average intelligence
High risk for anxiety and depression

51

Pervasive Development Disorder not Otherwise Specified (PDD-NOS)

Between Autism & Asperger's
Symptoms vary
Impaired social interaction
Fewer repetitive behaviors
Later age of onset

52

Autism Impairments

Social functioning
Language
Repetitive behaviors
Mental retardation
Seizures

53

Risk Factors for Surveillance for Autism Spectrum Disorder

Sibling with ASD
Parent concern
Inconsistent hearing
Unusual responsiveness
Caregiver concern
Pediatrician concern

54

Routine Screening for Autistic Spectrum DIsorder

Screen specifically at 18-24 months
MCHAT- modified checklist for autism in toddlers
STAT- screening tool for autism in toddlers & young children

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MCHAT Screening

16-48 months
Questionnaire
Interest in other children
Index finger to point/ indicate interest in something
Oversensitive to noise
Child imitate you

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Red Flags for Autistic Spectrum Disorder

Regression
"In their own world"
Lack of showing, sharing interest or enjoyment
Using caregivers hands to obtain needs
Repetitive movements with objects
Lack of appropriate gaze
Lack of response to name
Unusual prosody/pitch of vocalizations
Repetitive movements or posturing

57

Goals of Autistic Spectrum Disorder Treatment

Minimize core features
Maximum functional independence
Maximize QOL
Maximize family function

58

Comprehensive Treatment

Intervention immediately
25 hours/week year round in "systematically planned, developmentally appropriate educational activities"
Low student:teacher ratio
Inclusive experience with developing peers

59

Educational Interventions for Autistic Spectrum Disease

Applied behavioral analysis
Structured teaching
Developmental
Relationship focused
Speech & language therapy
Social skills instruction
OT

60

Common Behavioral Issues in Autistic Spectrum Disorder

Disruption/aggression
Self-injurious
Eating
Sleeping
Toileting

61

Medical Management of Autistic Spectrum Disorder

Challenges in routine health care due to difficulties wit social interaction, communication, & negotiating a new & unfamiliar environment
Visit time x2
Strategies in office to promote familiarity

62

Associated Medical Conditions

GI: chronic constipation/diarrhea
Recurrent abdominal pain
Seizures
Sleep problems

63

Define Oppositional Defiant Disorder (ODD)

Psychiatric disorder that is characterized by aggressiveness and tendency to purposefully bother & irritate others
Negative, manipulative, hostile, & deviant behavior

64

Etiology of Oppositional Defiant Disorder (ODD)

Family history

65

DSM-5 Criteria for ODD

Four symptoms from categories (angry & irritable mood, argumentative & deviant behavior, vindictiveness)
Occurs with 1+ individuals who is not a sibling
Causes problems at work, school, or home
Occurs on its own
Lasts at least 6 months

66

Symptoms of Angry & Irritable Mood in ODD

Often loses temper
Often touchy or easily annoyed by others
Often angry & resentful

67

Symptoms of Argumentative & Defiant Behavior in ODD

Often argues with adults or people in authority
Often actively defies or refuses to comply with adults' requests or rules
Often deliberately annoys people
Often blames others for mistakes or misbehavior

68

Symptoms of Vindictiveness in ODD

Often spiteful or vindictive
Shown spiteful or vindictive behavior at least twice in 6+ months

69

Prognosis of ODD

Some outgrow this
May turn into something else
May have without anything else
ODD + comorbid anxiety, ADHD, or depressive disorders

70

Treatment for ODD

Referral to pediatric psychiatrist
Meds for co-morbid disorders
Behavioral therapy
Parental therapy for setting clear boundaries

71

Define Conduct Disorder (CD)

Group of behavioral and emotional problems in children
Significant difficulty following rules & behaving in a socially acceptable way
"Bad" kids or delinquents

72

Factors that Contribute to Conduct Disorder (CD)

Brain damage
Child abuse
Neglect
Genetic vulnerability
School failure
Traumatic life experiences

73

Conduct Disorder vs. ODD

Conduct disorder worse version of ODD
ODD have worse social skills
ODD do better in school
CD most serious childhood psychiatric disorder

74

Co-morbid Conditions Associated with CD

Depression/anxiety disorders
PTSD
Substance abuse
ADHD
Learning problems
Bipolar disorder
Tourette's syndrome

75

Conduct Disorder Characterized by

Aggression to people & animals
Destruction of property (arson)
Deceitfulness, lying or stealing
Serious violations of the rules

76

Characteristics of CD for Aggression to People & Animals

Bullies, threatens or intimidates
Physical fights
Use of weapons to harm others
Physically cruel to people or animals
Steals
Forces others into sexual acts

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Treatment for Conduct Disorder

Referral to Psychiatrist for behavioral therapy, psychotherapy, parental support & training, meds for comorbid conditions

78

Prognosis of Conduct Disorder

Similar problems into adulthood
Likely to have personality disorder
Abuse of substances 4 years later
Cigarett smoking

79

DSM-5 for Depression

Depressed mood
Diminished interest or loss of pleasure in almost all activities
Sleep disturbance
Weight change
Appetite disturbance
Failure to achieve weight gain
Decreased concentration or indecisiveness
Suicidal ideation
Psychomotor agitation or retardation
Fatigue or loss of energy
Feelings of worthlessness or appropriate guilt

80

Medical Evaluation to Rule Out Etiologies

Infection
Medication
Endocrine disorder
Tumor
Neurologic disorder
Misc. disorders

81

Acronym for Signs/Symptoms of Major Depression

SIG
E
CAPS

82

Signs & Symptoms of Major Depression

S- sleep disturbance
I- interests
G- guilt
E- energy
C- concentration problems
A- appetite change
P- pleasure
S- suicidal though/actions

83

Treatment for Depression

Psychotherapy
Medical therapy
Combination of both

84

Medical Treatment of Depression with SSRIs

Fluoxetine (Prozac)
Escitalopram (Lexapro)

85

SSRI Black Box Warning

Increase suicide risk
Weigh risks vs. benefit