Peds- behavioral pt 1

Psychiatric Disorders in Children and Adolescents

Psychiatric disorders are complex illnesses that produce profound psychosocial and physical consequences for both children and adults. These conditions are characterized by several key clinical realities:

• High Mortality and Morbidity: These illnesses carry significant risks to life and long-term health.

• Underdiagnosis and Undertreatment: Despite growing clinical recognition, these disorders remain underreported and underappreciated in most clinical settings, especially within pediatric medicine.

• Clinical Presentation: The severity and presentation vary widely among individuals. In pediatric patients, symptoms are often more subtle and less refined, requiring providers to tease out specific diagnostic clues.

Eating Disorders

There are several distinct eating disorders that clinical providers must be mindful of in pediatric and adolescent populations:

• Anorexia Nervosa: Characterized by severe caloric restriction and low Body Mass Index (BMI).

• Bulimia Nervosa: Characterized by recurrent episodes of bingeing and purging to prevent weight gain.

• Binge Eating Disorder: Can be associated with both anorexia and bulimia.

• Avoidant Restrictive Food Intake Disorder (ARFID): Involves decreased eating behaviors similar to those in anorexia and bulimia.

• Pica: Defined by the consumption of non-food items. Identifying markers include:

  • Children often eat items like ice chips.

  • Textbook cases involve iron deficiency where children have a heavy preference for milk (which can interfere with iron absorption).

  • Potential for lead toxicity.

• Rumination Disorder: A behavioral condition where a child chews on food, pouches it, and then regurgitates it.

  • Common in children with cognitive or developmental issues (e.g., those on the neurodivergent spectrum).

  • Not generally a serious medical condition unless it leads to inadequate nutrition or dental caries.

Anorexia Nervosa

Anorexia is more common in females than males and is relatively common among adolescents. The hallmark of the condition is severe caloric restriction.

Case Presentation: 14-year-old Female

• Reason for Admission: Severe bradycardia with a resting heart rate of $40\,\text{bpm}$.

• Electrocardiogram (EKG) Findings: Prolonged QTC of $476$.

• History of Present Illness: Weight drop of $11\,\text{kg}$ in the last six months following a shift to a vegan diet and increased running.

• Associated Symptoms: Worsening constipation. Menstrual cycles were historically regular after the first year of menarche but have become irregular.

• Growth Curve: The patient was at the $60\text{th}$ percentile for weight since age $5$, but her percentile dropped significantly over the last six months.

• Clinical Management: Following inpatient support for mental health and nutrition, the patient consumed all subsequent meals in their entirety. Adequate caloric intake led to steady weight gain and the resolution of the prolonged QTC.

DSM-5 Diagnostic Criteria

• Restricted Intake: Restriction of energy intake relative to requirements, leading to significantly low body weight in the context of age, sex, developmental trajectory, and physical health. These requirements vary based on metabolic needs (e.g., high-performance athletes).

• Fear of Weight Gain: Intense fear of gaining weight or becoming fat, even though the weight is significantly low.

• Disturbed Perception: Disturbances in the way body weight or shape is experienced, excessive influence of weight on self-evaluation, or persistent lack of recognition of the seriousness of current low body weight.

Subtypes of Anorexia

• Restricting Type: Weight loss is accomplished primarily through dieting, fasting, or excessive exercise. Patients may exhibit patterns such as binging/fasting cycles (e.g., 23 hours without eating followed by a one-hour window).

• Purging Type: Patients may engage in self-induced vomiting or the misuse of laxatives, diuretics, or enemas.

Clinical Diagnosis and Physical Examination

Diagnosis is clinical and depends on a thorough history and physical exam rather than a single lab test.

• History Taking: Conduct a 24-hour diet recall (it is easier for patients to remember the last 24 hours than the last three days). Inquire about menstrual history (amenorrhea is a major red flag) and family history of psychiatric disorders.

• Vital Signs: Essential to monitor for bradycardia and orthostatic changes.

• Growth Curve: Evaluate height velocity; patients often drop off the curve.

• Physical Findings: Constipation (palpable stool in the left lower quadrant), edema, muscle atrophy, weakness, and hair loss.

Laboratory and Diagnostic Testing

While labs do not diagnose anorexia directly, they provide a measure of illness severity:

• Complete Metabolic Panel (CMP): To check for electrolyte derangements.

• Liver Function Tests (LFTs): To evaluate albumin and total protein as proxies for acute nutrition.

• CBC: To screen for mild anemia or malabsorption issues.

• Thyroid Tests: Some thyroid conditions can mask or mimic symptoms of anorexia.

• EKG: Performed primarily to screen for conduction abnormalities. Electrical derangements can lead to QT prolongation and eventual arrhythmia or cardiac arrest, often due to potassium imbalances ($K^+$) that stabilize cardiac conduction.

Bulimia Nervosa

Bulimia involves recurrent episodes of binge eating followed by inappropriate compensatory behaviors (purging) twice a week for at least three months. It has a prevalence of approximately $3\%$ in adolescent girls, typically appearing in late adolescence (ages $16$ to $17$) and early twenties.

Clinical Features

• Weight Profile: Patients usually have normal or above-normal body weights.

• Physical Indicators:

  • Dental caries (due to stomach acid exposure during vomiting).

  • Bad breath (halitosis).

  • Parotid gland swelling.

  • Russell's Sign: Scarring or calluses on the knuckles from self-induced vomiting.

• Case Example: A patient with alcohol use, self-harm (cutting on arms/thighs), and a BMI of $22$. Electrolyte lab showed a potassium of $3.3$, which is low-ish/mildly low.

Medical Complications of Purging

• Electrolyte Derangements: Hypokalemia and hypochloremia.

• Acid-Base Imbalance: Persistent vomiting leads to metabolic alkalosis (loss of acid), whereas laxative-induced diarrhea can lead to bicarbonate loss and a mixed picture including metabolic acidosis.

• GI Issues: Mallory-Weiss tears (esophageal tears) in severe cases.

Treatment and Prognosis for Eating Disorders

• Multiproprong Approach: Involves treating underlying nutritional deficiencies via inpatient or outpatient rehab alongside psychotherapy.

• Therapy: Cognitive Behavioral Therapy (CBT) combined with pharmacotherapy is most effective.

• Pharmacotherapy: Selective Serotonin Reuptake Inhibitors (SSRIs) such as Fluoxetine are the mainstay for adolescents.

• Refeeding Syndrome: A life-threatening complication characterized by widespread organ dysfunction. It is primarily a phosphorus issue ($PO_4^{3-}$) occurring when severe restriction is ended too quickly, causing rapid electrolyte shifts into cells.

• Prognosis: Younger patients generally have better outcomes. Bulimia has a lower mortality rate than anorexia (approximately $50\%$ recovery by five years) but is associated with higher rates of suicide.

Major Depressive Disorder (MDD)

MDD is common in adolescence, with a lifetime prevalence of $12\%$ to $15\%$ by age $17$. It is higher in girls ($16\%\text{--}18\%$) than boys ($7.7\%$).

Risk Factors and Pathogenesis

• Multifactorial Causes: Genetic predisposition combined with acute and chronic stressors (e.g., parental loss, abuse, educational pressure).

• Social Factors: Social media has increased pressure on children. Social determinants of health, such as those seen in underserved populations (e.g., Harlem or South Bronx), significantly impact risk.

• Vulnerable Populations: Individuals identifying within the LGBTQ+ community or those with chronic medical illnesses are at higher risk.

Diagnostic Criteria

• Duration: At least a two-week period representing a change in previous functioning.

• Core Symptoms: Must have either depressed mood or loss of interest/pleasure (anhedonia). Examples include an athlete suddenly quitting a favorite sports team or a child withdrawing from friends to play computer games in isolation.

• Physical Symptoms: Fatigue, sleep disturbances (insomnia or hypersomnia), and restlessness.

Clinical Management

• Screening: Use tools like the PHQ-9 or the GLAD (anxiety/depression screening). Every adolescent should be screened during visits using the HEDS exam (Health, Education, Drugs, Sexuality).

• Patient Interview: Speak with the family together, then ask parents to leave to interview the child alone. Emphasize confidentiality unless there is a risk of harm to themselves or others.

• Safety Planning: Directly asking about suicide does not increase risk; it is a protective measure to establish a safety plan.

• Therapy: Referral for CBT is essential as most primary providers are not qualified to perform it.

Anxiety Disorders

Anxiety disorders are the most common psychiatric illness in children and adolescents, with a prevalence of $10\%$. Onset can occur as early as preschool.

Developmental Fears vs. Disorders

• Normal Fears:

  • Infancy: Loud noises, strangers, separation.

  • Preschool: Separation, monsters, storms.

  • School Age: School performance, social fitting in, death of a loved one, health concerns.

• Anxiety Disorder: Anxiety that is disproportionate to the stressor, has a long duration, and interferes substantially with functioning.

Common Pedatric Anxiety Disorders

• Separation Anxiety Disorder: Common in 3-4 year olds; fear that parents will die or never return when away at school.

• Specific Phobias: (e.g., arachnophobia). Best managed with CBT.

• Generalized Anxiety Disorder (GAD): Excessive worry about routine events, like homework.

• Others: Social Phobia, OCD, and Panic Disorder.

Pathogenesis and Treatment

• Pathogenesis: Dysregulation of metabolic mechanisms leading to an over-response to stressful stimuli, including inappropriate adrenaline release causing tachycardia.

• Management: CBT and SSRIs are first-line treatments. Non-specific support includes sleep hygiene, regular exercise, and healthy eating.

Questions & Discussion

• Question regarding Lab Deficiencies: Do you see deficiencies in labs for anorexia?

  • Response: Yes, but they are not diagnostic of the condition. Unlike an X-ray for a broken arm, no lab or imaging tells you "this is anorexia." Electrolyte derangements are common but also occur in conditions like mild dehydration or gastroenteritis. Labs determine the severity of the illness.

• Question regarding EKG Necessity: Why perform an EKG for these patients?

  • Response: To screen for QT prolongation, which can lead to conduction abnormalities and cardiac arrest. This is particularly relevant when monitoring potassium ($K^+$) levels, which are critical for cardiac stability.

• Question regarding Bulimia Labs: Do you expect different electrolyte abnormalities with laxatives versus vomiting?

  • Response: Yes. Vomiting involves losing gastric acid, typically leading to metabolic alkalosis. Laxative use leading to diarrhea involves bicarbonate loss, potentially leading to acidosis. In chronic cases (6+ months), the body is often smart at correcting these, resulting in mixed or stabilized pictures.