Week 7 mental health

Question 1

AAP recommends anticipatory guidance about discipline at every health visit between ages _____ and _____

Answer 1

9 months to 5 years

	○ "How does **** get along with friends and family?" 
	○ "Parents of kids around ***'s age frequently worry about discipline. I wonder if you have any questions or concerns" At age 5: starting discussion on shift towards parental monitoring

Question 2

DISCIPLINE

time outs

Timer: ___ minutes per ___ of age

Answer 2

1 minute per year of age

* Child put in a neutral or boring environment after inappropriate behaviour
* Kids need to understand rules ahead of time and WHY behaviour is unacceptable
* Should use a timer: 1 minute per year of age
* Pick a boring area
* If child acts unacceptably in the middle of time out: reset timer
* Allowed to go to bathroom for one trip, but timer is reset

Question 3

AUTISM

impairments in:

Answer 3

• social communication

- restrictive, repetitive, stereotypic behaviours/interests

Question 4

AUTISM

symptoms usually emerge between (age) _______

Answer 4

12-24 months old

Question 5

AUTISM

risk factors

Answer 5

• older parental age
• preterm birth
• low birth weight
• jaundice
• male
• maternal obesity, DM, HTN
• close spacing of pregnancies
• rubella

Question 6

AUTISM

when should standardized screening be done?

Answer 6

18 and 24 months

CPS recommendation: developmental surveillance at every scheduled health visit (ie well baby check) and any time parent/caregiver raises concerns re: language/skills development
***Ask at EVERY visit if parents have developmental concerns

Question 7

AUTISM

4 domains of development to assess

ASD shows most significant delays in which 2 domains?

Answer 7

fine motor
gross motor
language
social development

ASD:

• language
• social development

Question 8

AUTISM

common behaviours/red flags

Answer 8

• decreased eye contact
• limited convo/too much (only talk about things that interest them, not other people’s interest)
• PHYSICAL INTERACTION on their own terms
• PATTERNS, resist change
• SOCIALLY insensitive
• SENSORY processing

Question 9

AUTISM

what is the major determinant of ultimate outcome?

Answer 9

2 years of early intervention before age 5

Question 10

ADHD

3 domains

Answer 10

inattention
hyperactivity
impulsivity

Question 11

ADHD

risk factors

Answer 11

• family hx
• in utero ETOH/nicotine exposure
• extreme preterm birth
• brain injury/stroke
• severe early deprivation/neglect, maltreatment
• comorbid MH

Question 12

ADHD

symptoms

Answer 12

• selective attention (over-focus on favourite activity)
• easily distracted
• inability to complete tasks
• blurting out/interrupting others
• social disinhibition

Question 13

ADHD

symptoms must be present before age _____

must exist in _____ and for at least ______

Answer 13

age 12

at least 2 contexts (eg school, home)

at least 6 months

Question 14

ADHD

rule out co-morbid conditions eg….

Answer 14

• depression (PHQ-9)
• anxiety (GAD-7)
• substance (CRAFFT)
• sleep disorder
• mania

(SADSM)

Question 15

ADHD

frequency of visits

Answer 15

2-4 visits over 1-2 months until stable

then
q3-4 months

Question 16

ADHD

first line treatment

Answer 16

behaviour modification

eg change physical environment

• clear boundaries re: behaviour
• positive reward for target outcome
• single step instructions

Question 17

ADHD

first line
psychostimulants

common side effects

Answer 17

long acting stimulants

common s/e:

• decreased appetite
• abdo pain
• headache
• insomnia
• jitteriness

at higher dose: growth suppression

Question 18

ADHD psychostimulants

contraindications

Answer 18

• untreated hyperthyroid
• glaucoma
• mod to severe HTN
• pheochromocytoma
• symptomatic CVS disease
• hx mania psychosis

Question 19

ADHD psychostimulants

caution with prescribing

Answer 19

• tics
• kids <5 or <20 kg
• substance use disorder
• renal impairment
• epilepsy
• Raynaud’s

Question 20

ADHD

monitoring while on stimulants

Answer 20

• wt
• ht
• BP and HR
• priaprism
• developmental milestones
• Pharmanet
• ADHD scales

*routine ECG not needed

Question 21

ACE

3 categories

Answer 21

• abuse (emotional, physical, sexual)
• neglect (emotional, physical)
• household dysfunction (domestic violence, incarcerated family member, mental illness, parent separation/divorce, substance/ETOH use)

Question 22

Define social determinants of health

Answer 22

environmental conditions where kids are born, grow, live, play, work and age
• SDOH responsible for most health inequities (WHO)
“the unfair and avoidable difference in health status seen within and between countries”

Question 23

Substance use during adolescent period of brain development adversely affects wiring of ________ cortex

Answer 23

prefrontal

-responsible for executive function (impulse control, attention, organization, planning, mood)

Question 24

ACE

what is the biologic mechanism that ACE adversely impacts health?

Answer 24

excess activation of stress response (toxic stress response)

• stress response chronically activated
• no buffers to assure child they are safe

Question 25

ACE what are some protective factors?

Answer 25

close relationships - parental resilience - positive parenting - social connections - concrete support (reliable adult) - sense of purpose (faith, culture, identity) - individual competencies

Question 26

ACE difference between primary and secondary prevention

Answer 26

Primary prevention: -prevent ACEs from happening Secondary prevention: -prevent complications • Primary Prevention: reduce exposure to stressors and create buffers ○ Society, neighbourhood, school, family, caregiver, child ○ Parenting programs ○ Legal rights for family leave, poverty reduction strategies, neighbourhood safety programs ○ Reach Out and Read literacy initiative ○ Promote self regulation in child eg games that help kids make choices (Simon Says, Red Light Green Light) • Secondary Prevention ○ Screening for maternal depression, hostile parenting, food insecurity, developmental delays Providing links to community resources

Question 27

PHYSICAL ABUSE sentinel injury definition

Answer 27

minor injury underappreciated by the parent or caretaker --> warning signs of future, more severe abuse • Eg bruise in pre-mobile infant, subconjunctival hemorrhage, frenulum injury • Crying or refusal to walk / move extremity

Question 28

PHYSICAL ABUSE suspicious injuries

Answer 28

bruises in soft tissue areas - retinal hemorrhages in infants (most often head trauma) - damage to oral mucosa - long bone fractures - circumferential burns - fractures to rib/sternum/scapula Increased index of suspicion: - changing history or history inconsistent with injuries - history that does not match developmental capabilities - unwitnessed injury in young kids

Question 29

what is most common trigger for head injuries?

Answer 29

crying prevention: pre-emptive discussion re: challenging developmental stages

Question 30

common causes of labial adhesion

Answer 30

- poor hygiene - recurrent vulvovaginitis - trauma

Question 31

Most common adverse birth outcome linked to IPV in pregnancy

Answer 31

low birth weight

Question 32

US preventative task force recommendation: | -who should be screened for IPV?

Answer 32

screen all women of childbearing age -written self-administered screening more sensitive and preferred

Question 33

Child injuries unusual areas for accidental injuries

Answer 33

``` neck ear cheeks medial thighs genitals ```

Question 34

components of safety assessment

Answer 34

- ESCALATING violence? - SEVERITY of abuse in the past - COMFORT with returning home? - CHILDREN - WEAPONS - SUBSTANCE/MENTAL health issues in perpetrator - SUPPORT network

Question 35

CRAFFT how many YES answers suggest serious problem?

Answer 35

CAR (passenger or driver under influence) RELAX (have you ever used substances to relax/feel better about self/fit in) ALONE (do you use alone) FORGET (do you ever forget things while using) FAMILY or FRIENDS (do they tell you to cut down) TROUBLE (have you ever gotten into trouble while using substances) 2+ YES is a positive screen

Question 36

CRAFFT brief counselling 5 steps

Answer 36

- REVIEW in detail - RECOMMEND not to use - RIDING/DRIVING risk counselling - RESPONSE: self-motivational statements - REINFORCE self-efficacy

Question 37

Phobia definition

Answer 37

Overwhelming, intense, highly specific, and often irrational fears -DSM criteria: "excessive anxiety accompanied by worry occurring more often than not for at least SIX MONTHS AND One or more of the following: restlessness, easy fatiguability, difficulty concentrating, irritability, tense muscles, disturbed sleep

Question 38

Anxiety definition of anxiety problem vs disorder

Answer 38

fear without definable source anxiety problem: significant but not severe distress disorder: -excessive, impairs functioning, lasts longer than 4 weeks

Question 39

ANXIETY children between ages _____ is in age of anxiety

Answer 39

2 to 5 years old - strong imaginations - fear of medical environment, witches, monsters

Question 40

ANXIETY pathophysiology which neurotransmitters are elevated? what areas of brain implicated in anxiety disorders?

Answer 40

GABA norepinephrine serotonin amygdala prefrontal cortex

Question 41

ANXIETY what are two strategies parents can use to help kids who are fearful

Answer 41

- do not trivialize fears (validate feelings even if unfounded fears) - provide physical comfort, make kids feel safe and secure others: - try to recreate fear (eg noisy kettle) to show it is not scary - normalize fears with books about fear - empower them to conquer fear - create plan to deal with problem should fear actually happen

Question 42

SSRI common side effects

Answer 42

``` nausea sleep: insomnia, sedation headache sexual dysfunction tremor/agitation appetite change weight gain ```

Question 43

SSRI serotonin syndrome SHIVERS

Answer 43

- onset: abrupt - myoclonus and tremor SHIVERS - shivering - hyperreflexia / myoclonus - increased temp - vital sign instability - encephalopathy (delirium, obtunded) - restlessness - sweating

Question 44

OCD define: obsessions compulsions

Answer 44

OBSESSIONS - recurrent disturbing, intrusive impulses or images - themes: contamination, aggression, taboo, exactness, safety COMPULSIONS - repetitive behaviours/acts in response to obsession or rigid rules - reduce distress or prevent dreaded event but not connected to even realistically themes: cleaning, arranging, counting, hoarding, repeating activities

Question 45

OCD criteria for diagnosis

Answer 45

-time consuming obsessions and compulsions that impair day to day functioning over 1 hour/day

Question 46

ANOREXIA diagnostic criteria - refusal - fear - disturbance/denial - amenorrhea

Answer 46

- REFUSAL to maintain weight - intense FEAR of gaining weight - DISTURBANCE in way body weight/shape is experienced or DENIAL - AMENORRHEA x 3 consecutive menstrual cycles

Question 47

BULIMIA diagnostic criteria -two features that define episode of binge eating compensatory behaviour timeline

Answer 47

binge episode: - eating in discrete period of time unusual amount of food (compared to other people in similar period of time and similar circumstances) - lack of control over eating compensatory behaviour: vomiting, laxative/diuretics/enema, fasting, exercise occur on average minimum twice/week for 3 months

Question 48

BULIMIA example of purging and non-purging compensatory behaviours

Answer 48

purging: laxatives, diuretics, enemas nonpurging: fasting, excessive exercise

Question 49

what is a common co-morbid mental health diagnosis with restricting subtype anorexia? bulimia?

Answer 49

personality disorder cluster C (avoidant, OC, dependent) = restrictive anorexia cluster B (narcissistic, histrionic, borderline) = bulimia

Question 50

EATING DISORDERS SCOFF screening tool what is a positive screen?

Answer 50

over last 3 months: SICK - do you make yourself sick due to feeling uncomfortably full -CONTROL - do you feel you have lost control on eating -ONE STONE - have you recently lost >1 stone (14 lbs - 6.4 kg) -FAT - do you feel you are too fat -FOOD - does food dominate your life positive answer to any question

Question 51

EATING DISORDER what are some physical signs? - VS - CVS - hair - skin - ENT - Russell

Answer 51

VS: orthostatic drops, hypothermia CVS: murmur (mitral valve), sinus bradycardia HAIR: dull, thinning SKIN: carotenemia, dry and sallow, lanugo ENT: sialoadenitis (parotitis), angular stomatitis, oral ulcerations, dental enamel erosions Russell sign: callous on knuckles from self-induced emesis

Question 52

EATING DISORDER labwork

Answer 52

``` ○ ECG ○ CBC ○ Electrolytes ○ Glucose ○ Calcium ○ MgSo4 ○ Phosphate ○ TSH ○ LFTs ○ BUN, creatinine ○ UA ```

Question 53

EATING DISORDER -indications for hospitalizations in youth weight: HR: orthostatic changes: SBP: CVS: GI:

Answer 53

weight: <75% ideal body weight or ongoing weight loss - body fat <10% HR: <50 bpm daytime, <45 bpm nighttime Orthostatic: HR increase >20 bpm or >10-20 mmHG drop in BP SBP <90 CVS: cardiac arrhythmias, syncope GI: intractable vomiting, hematemesis, dehydration

Question 54

EATING DISORDERS chronic medical conditions associated with eating disorders

Answer 54

- type 1 DM - IBD (Crohn's, ulcerative colitis) - celiac - cystic fibrosis - illnesses requiring long term steroids

Question 55

EATING DISORDERS what is the best way to assess risk in children and adolescents?

Answer 55

plot ht and wt on growth chart (compare previous measurements)

Question 56

EATING DISORDERS most common cause of death? most common medical cause?

Answer 56

suicide is most common cause of death for anorexia and bulimia -highest mortality of any mental illness medical cause: cardiac arrhythmias from electrolyte disturbance

Question 57

TICS definition

Answer 57

brief, abrupt non-purposeful movement -repetitive, involuntary, can be suppressed

Question 58

TICS risk factors

Answer 58

OCD self-conscious shy children family hx PANDAS

Question 59

TICS characteristics

Answer 59

repetitive movement - worsened by stress and emotions - brief premonition indescribable and uncomfortable, relieved by tic

Question 60

TOURETTE SYNDROME diagnostic criteria

Answer 60

multiple motor and vocal tics variably manifested over time present for >1 year onset before age 21 not caused by another condition

Question 61

TICS first line pharmacotherapy and drug class?

Answer 61

clonidine alpha adrenergic agonist alternative: guanfacine

Question 62

are long-acting stimulants contraindicated in kids with Tourette's?

Answer 62

no, not all patients with TS will have worsening tics

Question 63

FASD diagnostic criteria (3 domains)

Answer 63

facial features (all 3) - short palpebral fissure - smooth philtrum - thin upper lip Growth delay -height or weight at 10th percentile or less CNS abnormality - structural - neuro (eg seizure, motor delay) - functional (eg cognitive, developmental, social, sensory etc)