Peds E1- Behavioral

What behavioral are considered normal when a new sibling arrives?

Universal rxn: hostility/aggressive behaviors, sad/withdrawn

Developmental regression: thumb sucking, bed wetting, baby talk

What can parent do to help older siblings adjust to have a younger sibling?

allow participation in planning for new arrival, help care for newborn, no changes right before arrival, set aside time for them, maintain routine as much as possible

What is a Temper tantrum?

Child cries and/or harms him/herself to manipulate the parents/guardians

When do temper tantrums usually resolve?

By age 5

How should you handle tantrums?

redirect child to something else, avoid provoking situation, ignoring the tantrum

What are breath holding spells?

Child holds their breath and suddenly loses consciousness

What are the 2 forms of breath holding spells?

Cyanotic and Pallid

Cyanotic or Pallid breath holding spell:

LOC → Breath holding

Pallid

Cyanotic or Pallid breath holding spell:

Crying → Breath holding → cyantoic → LOC

Cyanotic

Are cyanotic or pallid breath holding spells more common and is related to a temper tantrum?

Cyanotic

What is the most common neurobehavioral disorder of childhood?

ADHD

What is ADHD?

Chronic pattern of attention difficulties, impulsivity, and/or hyperactivity that interferes with daily life

Is ADHD more common in males or females

males

What is the diagnostic criteria for ADHD?

6+ sx x min 6 months (inattention & hyperactivity), inconsistent w/ developmental level, have negative impacts on social/academic activities, present in 2+ settings

What is the gold standard questionnaire for diagnosis of ADHD?

*> 90% sensitivity & specificity

Conner's scale

What questionnaire is designed for Teacher/Parents and commonly used to dx ADHD?

*high sensitivity & specificity if both used

Vanderbilt ADHD Diagnostic rating scale

Which questionnaire is good for monitoring the effectiveness of medications in children with ADHD?

Conner's scale

What are some long term implications of ADHD?

School failure, Poor social relationships, Poor self esteem

What is the tx for ADHD?

Medication + Behavioral therapy combo

What stimulant is commonly used for ADHD?

Methylphenidate (Ritalin)

What lifestyle changes can help manage ADHD?

avoid heavy metals, try high PTN & low carb, more water, healthy sleep, cut sugar, caffeine, dairy, food coloring etc

Which ADHD medications are stimulants?

Ritalin, Concerta, Adderall, Vyvanse

What is a common side effect of Ritalin?

reduced growth, wt loss, poor weight gain

Which stimulant has an ER formulation and allows more time for homework at the end of the day?

Concerta

What is Adderall made of?

mixed salts of dextroamphetamine & amphetamine

Which stimulant is less addictive than Adderall and Concerta?

Vyvanse

Which medications are non-stimulant tx for ADHD?

Stattera, Intuniv

Which ADHD medications have less appetite suppression?

Non-stimulants: Stattera and Intuniv

Which ADHD medication can be used with other psychiatric disorders, such as depression & bipolar?

Wellbutrin (Bupropion)

What are the three subtypes of ADHD?

1. Inattentive

2. Hyperactive-impulsive

3. Combination of both

Aggression/Disruptive behavior disorders are caused by a mixture of what factors?

genetics, prenatal, social/environmental

What is Oppositional defiant disorder?

Pattern of negative, hostile, and defiant behavior that is excessive compared with other children of the same age for at least 6 months

What is the ODD-DSM criteria?

A: pattern of negativistic, hostile, and defiant behavior x 6 months

• At least 4 sx: loses temper, argues w/ adults, actively defies requests/rules, deliberately annoys ppl, blames mistakes on others, easily annoyed, angry/resentful, spiteful/vindictive

B: disturbance causes impairment in social, academic, occupation

C: do NOT occur during the course of Psychotic/Mood disorder

D: criteria for Conduct disorder (18+ Antisocial personality disorder) are not met

What is the tx for oppositional defiant disorder?

Psych eval, Family/social skills training, pharmacotherapy

What is Conduct disorder?

Repetitive/persistent pattern of behavior in which the basic rights of others or major age-appropriate societal norms and rules are violated

What age can conduct disorder be diagnosed?

>7 y/o

What is conduct disorder associated with?

harsh discipline, abuse, neglect

What is the DSM criteria for Conduct disorder?

A: 3 criteria w/in 12 months, at least 1 w/in the past 6 months

Categories:

• Aggression to people & animals

• Destruction of property

• Deceitfulness or theft

• Serious violations of rules

B: behavior impairs social, academic, occupational fxning

C: if 18+, criteria for Antisocial Personality Disorder are not met

What is the tx for conduct disorder?

Behavioral therapy, Psych referral, Meds

ODD or CD:

Defiance of rules and argumentative verbal interactions

ODD

ODD or CD:

Symptoms emerge during pre-school years and persist for at least 6 months

ODD

ODD or CD:

Deliberate aggression, destruction, deceit, and serious rule violations, such as staying out all night or chronic school truancy

CD

ODD or CD:

Clear pattern of behavior established over a 6 month period

CD

What is Intermittent explosive disorder?

Repeated episodes (10-20 min) of aggressive, violent behavior with reactions grossly out of proportion to the situation, associated with feelings of remorse after episodes

What is Bullying?

Any unwanted aggressive behavior(s) by another youth or group of youths that involves power imbalance and is repeated or likely to be repeated multiple times

What does bullying put kids at higher risk for?

injury, social/emotional distress, depression, anxiety, sleep difficulties, lower academic achievement, substance abuse

In cases of bullying/aggression, what can be done to help find out the "truth"?

Interview without the parent

Which class of ADHD medications tends to cause weight loss, appetite suppression, and insomnia?

Stimulants

Which ADHD medications might be a good choice for a child who is a picky eater and has trouble gaining weight?

Non-stimulants (Strattera or Intuniv)

What are the 3 types of depression in childhood/adolescence?

1) Major Depressive Disorder

2) Dysthymic disorder

3) Adjustment disorder with depressed mood

Which type of childhood/adolescent depression:

Depressed or irritable mood or markedly diminished interest and pleasure in almost all the usual activities, or both, for a period of at least 2 weeks

Major Depressive Disorder

Which type of childhood/adolescent depression:

Depressed or irritable mood for most days in the past 2 years that is less intense but more chronic than major depressive episodes

Dysthymic disorder

Which type of childhood/adolescent depression:

Occurs within 3 months after a major life stressor, involves less severe symptoms and relatively mild and brief

Adjustment disorder with depressed mood

What are the signs of Depression that you need to watch for?

SIGECAPS

Sleep changes, Interest loss, Guilt, Energy low, Concentration low, Appetite change (inc/dec), Psychomotor fxn (agitation/hopeless), Suicide

What questionnaire screens for Depression?

PHQ-9

What mental health disorder is commonly also present in pts w/ depression?

Anxiety

What is the 2nd leading cause of death among adolescents 15-24 years of age in the U.S.?

Suicide

What is Panic/Anxiety disorder?

Unexpected, repeated periods of intense fear and discomfort along with somatic symptoms such as increased heart rate and SOB

What is the tx for panic/anxiety disorder?

Psychotherapy (CBT)

What is Anorexia?

Loss of appetite

What is Anorexia nervosa?

Hungry, but restricts food intake

What is Bulimia?

Vomits usually within 2 hours of overeating due to over-concern of weight gain

What is Binge eating disorder?

Binging without purging

What is a Binge?

Overeating

What is Purging?

Eliminates food by vomiting or laxative

What are signs of Anorexia Nervosa?

over-concerned w/ dieting and body weight, body dysmorphia; tend to be meticulous, compulsive, intelligent

What is the most effective treatment for anorexia nervosa if tx w/in 6 months or less?

Psychotherapy

What BMI is needed to diagnose anorexia nervosa?

<18.5 or loses >25% of ideal body weight

What is the tx for bulimia nervosa?

Psychotherapy + SSRI

What are symptoms of Bulimia Nervosa?

uses diuretics/laxatives, self induces vomiting → metabolic alkalosis, dec HR, BP

Patient presents with swollen salivary glands, scars on knuckles, erosion of tooth enamel, and hypokalemia. What do you suspect?

Bulimia nervosa

What is cannabis use associated with?

reduced IQ, dec neural connectivity, Inc risk of depression, suicidality, psychosis

When should you start screening for use of alcohol, tobacco, and illicit drugs?

Age 11

What are some s/s of alcohol and drug abuse?

Decreased school performance, Change in peers, Delinquent behavior, Deterioration of family relationships

What is Bipolar disorder?

Manic episodes alternating with depression episodes and normal moods

What is the pharmacological treatment for bipolar disorder in peds?

1st line: 2nd gen antipsychotics

2nd line: Lithium

What is the non-pharmacoloical treatment for bipolar disorder in pediatrics patients?

Psych referral, Hospitalization

Why is bipolar disorder difficult to diagnose in the youth?

Difficulty expressing emotions, Developmental issues

Patient presents with increased activity/silliness beyond what is expected of their age. Parent reports they have noticed inappropriate sexual behaviors from the child without exposure to sexual activity. They also have decreased need for sleep. What diagnosis do you suspect?

Bipolar disorder

What is Munchausen syndrome by proxy (MSB)?

A potentially lethal and frequently misunderstood form of child abuse (parent makes the child sick)

In cases of Munchausen syndrome by proxy, who is the perpetrator in the majority of cases?

Mother

When do the child's symptoms usually occur in cases of Munchausen syndrome by proxy? When do they subside?

Occur in presence of parent/caregiver, Subside in their absence

What 2 factors are required to make the diagnosis of Munchausen syndrome by proxy?

1) Harm/potential harm to child from excessive intervention

2) Caregiver is fabricating illness or pursuing unnecessary treatment

NREM or REM:

Parasomnias (night terrors, sleep walking)

NREM

NREM or REM:

Dreams

REM

NREM or REM:

4 stages of sleep

NREM

70% of infants sleep through the night by ____ months

9

What are characteristics of REM sleep in infants?

occurs at onset of sleep, more REM than older children and adults

What is the best way to handle a young infant waking in the night?

let sleeping infant lie (often parent is the cause), stop bad habits of night feeding/rocking; DAILY regular routine

What is the best way to handle an older infant awakening at night?

Ignoring it

What factor is important to consider when a toddler won't sleep? How can you educate the parents?

Consistent pre-sleep routine is imperative, Parent should respond with gentle but firm "no, it's bedtime."

What is Primary insomnia?

Conditioned anxiety about falling or staying asleep in older children, adolescents, and adults

What is the tx for primary insomnia?

R/o alternative explanations, Behavioral interventions

Which parasomnia:

Child awakened from a deep sleep during the first part of the night and sits up, appears dazed, and reacts slowly to questions

Confusional arousal

Which parasomnia:

"Sleep drunkenness"

Confusional arousal

Which parasomnia:

Child awakens screaming from stage N3 sleep with dilated pupils, sweating, & tachycardia (usually 18 mo - 6 yo)

Night terrors

Does the child remember a night terror?

No

What conditions may precipitate night terrors?

Stress, Illness, Sleep deprivation

Night terrors or Nightmares:

Stage 4 sleep, No recall, First 1/3 of night, Not consolable, confused/agitated

Night terrors

Night terrors or Nightmares:

REM sleep, May recall, Consolable, Second 1/2 of night, upset but awake

Nightmares