Developmental

1
Developmental Behavioral Disorders

• Clinical Medicine Surgery III
• Steve Sager, MPAS, PA-C

2
Learning Objectives

• List feeding disorders their management
• Define colic and list the treatment options
• Identify common eating disorders
• Differentiate between types of developmental
  disorders
• Discuss the etiologies of developmental disorders
• List the risk factors for developmental disorders
• Discuss treatments and parent education for
  temper tantrums breath-holding
• Identify the characteristics of common sleep
  disorders
• Discuss the etiology and treatment of enuresis
• Differentiate between various learning
  disabilities including dyslexia and ADHD

3
Learning Objectives

• Discuss the diagnostic criteria treatment of
  ADHD
• Define discuss the symptoms of mental
  retardation
• Discuss the treatment/management options of
  mental retardation
• Discuss the etiology of Cerebral palsy
• List the 5 clinical stages/manifestations of
  depression
• Discuss current treatment modalities for
  depression
• Discuss the incidence of adolescent suicide

4
Feeding Disorders

• Various reasons
• Common denominator is refusal of food
• Pain
• Frightened
• Emotional
• Developmental conflict
• Complete physical exam
• Social hx important - includes parents perception
  of behaviors and expectations
• CBC, CMP, and U/A
• Consider nutritional supplements
• Observe the feeding encounter
• Parent education

5
Feeding Disorders

• Underfeeding
• Restlessness, irritability and excessive crying
• Failure to gain weight
• ? Abnormal bonding
• Evaluate frequency, mechanics, eructation
• Overfeeding
• May be qualitative or quantitative
• Regurgitation and emesis
• Excessive weight gain

6
Feeding Disorders

• Malnutrition
• Improper or inadequate food intake
• Malabsorption
• Metabolic abnormalities
• Stress
• Disease
• Antibiotic therapy
• Take a thorough dietary history
• Review growth rate
• Check BMI

7
Feeding Disorders

• The best way to prevent feeding problems is to
  teach your children to feed themselves as early
  as possible
• Provide them with healthy choices and allow
  experimentation.
• Mealtimes should be enjoyable and pleasant and
  not a source of struggle.
• http//www.keepkidshealthy.com/nutrition/

8
Colic (Irritable Infant)(ICD 789.0)

• Symptom complex
• Paroxysmal abdominal pain and severe crying
• Occurs in infants
• Etiology (No single factor)
• Aerophagia
• Overfeeding
• Food allergies
• Anxiety, anger, fear, excitement
• High carbohydrate diet
• High fat diet

9
Colic

• Hx
• When and length of crying
• Exacerbating or palliative factors
• Familys ideas about etiology
• Sxs
• Sudden onset of loud, continuous crying
• 3 hours/day and 3 days/week
• Tense, distended abdomen
• Hands clenched
• Cold feet
• Legs are drawn up to abdomen
• Usually occurs in p.m.
• Symptoms persist for several hours

10
NOT Colic

• Failure to thrive
• Continuous irritability or after 4 months
• Vomiting
• Constipation/Diarrhea
• Anal fissures
• Heme-positive stool
• Rash
• Respiratory symptoms
• Point tenderness in extremities
• Dysmorphic facial features

11
Colic

• Perform a thorough physical examination
• R/O obstruction and intussusceptions
• Look for signs of abuse
• Dx of exclusion
• No consistent treatment
• Hold infant upright/Increased carrying
• Improve feeding techniques
• Promote stable environment
• Be supportive/sympathetic
• Reassure, Reassure, Reassure!!!
• 2ml of 12 sucrose solution
• Consider sedation

12
Eating Disorders

• Anorexia nervosa
• Bulemia nervosa
• Eating disorder NOS
• Obesity
• 15 of 6-19y.o. (25 are overweight)
• BMI above 95th percentile
• Familial predisposition
• Requires mental health evaluation

13
Risk Factors for Eating Disorders

• Dissatisfaction with body image
• Low self-esteem
• Depression
• Obsessive behaviors
• Early onset of menses
• Childhood sexual or physical abuse
• Affective disorders
• Anxiety disorders
• Personality disorders
• Environmental stressors

14
Medical Complications of Eating Disorders

• Cardiovascular dysfunction
• Endocrine abnormalities
• Musculoskeletal disease
• Gastrointestinal disturbances
• Parotid salivary gland hypertrophy
• Immune system deficiencies
• Electrolyte abnormalities
• Hair skin disorders

15
Medical Complications of Eating Disorders

• Secondary amenorrhea
• Delayed puberty
• Growth retardation
• Cardiac irregularities
• MVP
• Prolonged QT interval
• Orthostatic hypotension
• Pericardial effusions
• Heart failure

16
Detection Diagnosisof Eating Disorders

• Early intervention is essential
• Often referred by a concerned parent, friend,
  school nurse, or coach
• Patient presents with vague complaints
• Fatigue
• Dizziness
• Headache
• Constipation
• Dyspepsia
• Amenorrhea

17
Detection Diagnosisof Eating Disorders

• History
• How much would you like to weigh?
• How do you feel about your present weight?
• Are you concerned, or is anyone else concerned,
  about your eating or exercise habits?
• Psychosocial problems
• Substance abuse
• Aberrant sexual behavior
• Suicidal ideation
• Physical or sexual abuse
• Psychiatric comorbidities
• Mood disorders
• OCD

18
Additional Testing

• Lab
• CBC
• Electrolytes
• Serum glucose
• ECG
• EEG
• Bone density
• MRI brain

19
Anorexia nervosa(ICD 307.1)

• Patient exhibits a willful refusal to
• Achieve expected weight gain
• Maintain a minimally normal weight
• 15 below ideal body weight
• BMI
• Patient has an intense fear of weight gain and a
  significant misinterpretation of body shape
• Mortality 5-10
• Restricting or Binge-purge types

20
Signs Symptoms ofAnorexia nervosa

• Bradycardia
• Orthostasis
• Hypothermia
• Heart murmur
• Hair loss
• Pitting edema of extremities
• Emaciation
• Flat affect
• Acrocyanosis

21
Bulimia nervosa(ICD 307.51)

• Binge eating combined with inappropriate ways to
  prevent weight gain. (2 episodes/week)
• Self-induced emesis
• Laxatives
• Diuretics
• Enemas
• Strict dieting/fasting
• Extreme exercise
• Maintain 85 of ideal body weight
• Produces extreme guilt
• Characterized by impulsiveness and maladaptive
  behaviors

22
Signs Symptoms ofBulimia nervosa

• Bradycardia
• Orthostasis
• Hypothermia
• Heart murmur
• Dull hair
• Xerosis
• Parotitis
• Russells sign
• Mouth sores
• Dental enamel erosions

23
Eating disorder NOS(ICD 307.50)

• Patients do not meet the criteria for a specific
  eating disorder
• Binge eating disorder without inappropriate
  compensatory behaviors
• Patients are NOT fixated on body shape or weight
• Repeatedly chew and spit out food
• Menses are regular
• Normal weight

24
Indications for Hospitalization in Patients with
Eating Disorders

• Anorexia
• Body weight 25 below ideal
• Intractable weight loss
• Refusal to eat
• Prolonged QT interval
• Bradycardia
• Cardiac arrhythmias
• Temperature
• Symptomatic hypotension

• Bulimia
• VS changes
• Syncope
• Hypothermia
• Suicidal ideation
• ETOH or drug abuse
• Intractable emesis
• Hematemesis

25
Treatment of Eating Disorders

• AN
• Long-term
• Normalize body weight gradually
• Monitor electrolytes Q2-3D
• Psychotherapy medications prn
• Calcium Vitamin D supplements
• BN/EDNOS
• Short-term
• Establish a regular eating pattern
• Reduce disordered behaviors
• SSRIs

26
Childhood Obesity(ICD 278.0)

• 15 of 6-19 year olds are overweight
• 50-80 of overweight children will become
  overweight adults
• Due primarily to reduced physical activity and
  poor eating habits

27
Childhood Obesity

• Calculate BMI
• BMI-for age is now included on growth charts
• www.cdc.gov/growthcharts
• Check family history
• Obesity
• Heart disease
• HTN
• Eating disorders
• Hyperlipidemia
• Ask patient about weight concerns
• Monitor for large changes in BMI
• Check lipid profile and TFTs

28
Risk Factors for Obesity

• Genetic predisposition
• Heredity
• Diet
• Bottle vs. Breast feeding
• Early menarche
• High-risk behaviors
• Tobacco use
• ETOH consumption
• Limited physical activity
• Socioeconomic status

29
Health ProblemsAssociated with Obesity

• Hypertension
• Insulin resistance
• Type 2 diabetes
• Depression
• Low self-esteem
• Cholelithiasis
• Asthma
• OSA
• Sleep apnea

• Hypercholesterolemia
• Dyslipidemia
• Menstrual irregularities
• Pickwickian syndrome
• Steatohepatitis
• Genu varum
• Orthopedic problems
• Slipped capital femoral epiphysis

30
Obesity Prevention

• Identify and track patients at risk
• Calculate and monitor BMI
• Encourage/support breast-feeding
• Promote routine vigorous physical activity
• 60 minutes daily
• Limit TV/video games
• Recognize monitor for changes in risk factors
• Promote healthy eating patterns
• Nutritious snacks
• Set limits

31
Dietary Modificationsfor Childhood Obesity

• Well-balanced meals
• More fruits and vegetables
• More water
• Less sugar
• New food guide pyramids for children from USDA
  Center for Nutrition Policy and Promotion
• 6 years old www.usda.gov/cnpp
• Do not use food as a reward or punishment
• Do not eat while watching TV

32
Developmental Disorders

• Every child routine examination
• Denver Developmental Screening Test
• Determine if deviation of development is a result
  of delay, arrest, or deterioration
• May be related to
• Cultural issues
• Biological influences
• Psychological influences
• Social factors

33
Developmental Disorders

• Disruptive Behavioral Disorder
• Emotional disorders
• Antisocial behavior
• Habit disorders
• Sleep disorders
• Learning disabilities
• Dyslexia
• ADHD
• Mental retardation

34
Identifiable Causes

• Hypothyroidism
• Phenylketonuria
• Galactosemia
• Downs syndrome
• Fragile-X syndrome
• Congenital intrauterine infection
• Cerebral Palsies

35
Risk Factors

• Maternal health problems
• Diabetes, toxemia, viral infection, ETOH/drugs
• Teenage pregnancy
• 35y.o.
• Fetal distress during delivery
• Prematurity
• Breech delivery
• Small for gestational age
• Neonatal health problems
• Respiratory distress, seizures, infections
• Prolonged jaundice

36
Disruptive Behavioral Disorder

• Inappropriate behavior for age
• 50 of adolescents commit antisocial behaviors
• Lying
• Stealing
• Truancy
• Run-away behavior
• Fire-setting
• Aggression
• Cruelty to animals
• Property destruction
• Never developmentally appropriate
• Persists 6 months

37
Disruptive Behavioral Disorder

• Factors
• M F
• Size
• Brain damage
• Emotional disturbance
• School failure (severe reading retardation)
• Hyperactive
• Large family
• Parental discord
• Aggression may be instrumental or hostile
• Persists from early childhood

38
Disruptive Behavioral Disorder

• Passive-aggressive behavior
• Expressed as procrastination, stubbornness, or
  resistance
• Academic underachievement
• Low self-esteem
• Conduct disorder
• Characterized by several different behaviors
• Oppositional defiant disorder
• Defiance of rules
• Obscene language
• Continual blaming of others
• Temper tantrums

39
Emotional Disorders

• Temper tantrums, breath holding, lying
• Typical in 2-4 y.o.
• Typically result from frustration or anger
• An attempt to control their environment or
  caregiver or cover up disapproved activity
• May cause seizures
• DO NOT reinforce/punish the behavior!
• Encourage honest communication

40
Temper Tantrums

• An immature way of expressing anger and getting
  attention
• Increase with fatigue, hunger, and sickness
• BE CALM. NO ADULT TANTRUMS!
• Avoid spanking
• Ignore the behavior
• Dont react
• Remove yourself
• Pick your battles
• Shift the attention to something else
• Provide safety
• Verbalize/acknowledge the anger!

41
Breath Holding

• Spells can terrify a parent at first
• Occur in healthy children
• Usually start in first year and last up to 6
  years
• Usually a response to anger or mild injury
• Child is provoked, starts to cry, falls silent,
  turns color (cyanotic or pale)
• R/O seizures, orthostatic HTN, Rett syndrome,
  syncope, tumors

42
Breath Holding

• Mechanism of action
• Cyanotic Prolonged expiratory apnea
  hyperventilation cerebral anoxia
• Pallid Asystole reflex anoxic seizures
• Signs
• Cyanosis syncope brief tonic-clonic movements
• Rapid onset w/wo crying bradycardia seizures
  follows painful stimuli
• Focus of treatment is behavioral
• Protect from injury and maintain airway

43
Habit Disorders

• Head banging
• Body rocking
• Thumb sucking
• Nail biting
• Trichotillomania (hair pulling)
• Bruxism (teeth grinding)
• Hitting or biting self
• Tics
• Breath holding
• Repetitive vocalizations

44
Sleep Disorders

• May be temporary, intermittent, or chronic
• Prevalence 0.2-10
• Primary inability to fall asleep
• Secondary inability to remain asleep
• Infancy due to parental anxiety/strife
• Adolescents night-time fears
• Attempt to delay bedtime
• Try to sleep in parents room

45
Sleep Disorders

• Narcolepsy (ICD 347.0)
• Genetic predisposition
• Onset in adolescence
• Causes frequent daytime naps, cataplexy, and
  hypnogogic hallucinations
• Nightmares (ICD 307.47)
• Affect 7-15 (FM) of all children
• Anxiety dreams during REM with rapid return to
  lucid
• Recall the events of the dream
• Common in children with anxiety affective
  disorders

46
Sleep Disorders

• Night terrors (ICD 307.46)
• Usually affects pre-school children
• 2-5 (MF)
• Cause arousal from Stage 4 (non-REM) sleep
• Confused, frightened disoriented
• Increased autonomic activity
• Most frightening for parents - cannot awaken the
  child
• Glazed look, incoherent, unresponsive
• Scream thrash
• Last up to ½ hour - looks wide awake
• Goes back to sleep with no recollection
• Cannot recall events of dream

47
Sleep Disorders

• Somnambulism (ICD 307.46)
• Sleepwalking
• Occurs in 10-15 of school-aged children
• Familial disposition
• Associated with nocturnal enuresis
• Occurs during Stage 3 or 4 of sleep
• Can occur with night terrors
• Provide a protective environment

48
Sleep Disorders

• Dyssomnia
• Problem of going to sleep and nighttime awakening
• Annoying and frustrating for parent
• Define a schedule and routine
• Enforce wakeup time
• Napping at wrong times
• Minimize parental response
• History and sleep diary may help
• Make gradual changes

49
Sleep Disorders

• Management
• Parental support
• Reassurance/Encouragement
• Set a scheduled bedtime
• Quiet activities
• Allow child to sleep in a siblings room prn
• Night light/leave door open
• Warm bath
• Reading
• Benadryl

50
Enuresis(ICD 307.6)

• Involuntary discharge of urine
• After bladder control has been established
• 73 _at_ 5y.o.
• 32 _at_ 10y.o.
• 1 _at_ 18y.o.
• Familial pattern
• Primary (persistent) never dry (75)
• Secondary (regressive) dry 1 year
• Organic etiology is RARE!
• Check urinalysis

51
Primary Enuresis

• Nocturnal occurs throughout sleep cycle
• Coercive parents may generate angry response
• Inattentive parents may undermine attempts at
  bladder training
• Impaired control may also result from
• Social stress (overcrowding, school, etc.)
• Chronic psychological stress
• Immigration
• Socioeconomic disadvantage

52
Secondary Enuresis

• Brought on by stressful environmental events
• Moving
• Marital conflict/Divorce
• Birth of a sibling
• Death in the family
• Intermittent transitory

53
Enuresis(Management)

• Attempt to determine probable etiology
• Counsel parents and child!
• Charts and rewards
• Launder own clothing
• Limit p.m. liquids
• Void HS
• Avoid punishment/humiliation!!!!!!!
• Medications
• Imipramine (Tofranil) 25mg HS x4-5 months
• Desmopressin (DDAVP) Nasal spray

54
Learning disabilities

• May be due to
• Neurodevelopmental problems
• Global cognitive delay
• Primary attention deficit
• Emotional preoccupation
• Chronic illness
• Usually a combination of several factors
• Determine to underlying problem

55
Dyslexia

• Specific reading disability
• Primary or developmental defect
• Affects higher cortical processing of graphic
  symbols
• Letter or word reversal
• Mirror writing
• Achievement is below expectancy in reading and
  spelling ONLY!
• Not associated with ocular/visual problems
• Still requires ophthalmology evaluation

56
Dyslexia

• DDx
• Reading retardation
• Intellectual impairment
• Maturational delay
• Cultural/education deprivation
• Emotional disturbance
• Organic brain disease
• Sensory defects
• Alexia
• Tx remedial instruction

57
Attention Deficit and Hyperactivity Disorder
(ADHD)

• Etiology is not understood
• M F
• Primarily a disorder of cognitive impairment
• Characterized by
• Poor ability to stay on task
• Motor overactivity
• Impulsivity
• Must be differentiated from a learning disability
  and conduct disorder
• Children differ in cognitive style, levels and
  types of arousal, and response to rewards
• Symptoms may persist into adulthood
• Increased incidence of alcoholism and sociopathy

58
ADHD

• Behavioral problems in school
• Fidgety
• Easily distracted
• Difficulty remaining in their seats
• Difficulty awaiting their turn
• Difficulty following instructions
• Shift between uncompleted tasks
• Talk excessively
• Impulsively blurt out answers
• Intrude on others
• Frequently loose items
• Engage in dangerous physical activities

59
Symptoms of Inattention

• Often ignores details (makes careless mistakes)
• Has trouble sustaining attention in work or play
• Does not seem to listen when directly addressed
• Does not follow through on instructions
• fails to finish
• Has difficulty organizing tasks and activities
• Avoids activities that require a sustained mental
  effort
• Often loses things he or she needs.
• Gets distracted by extraneous noise.
• Forgetful in daily activities.
• (Obviously the opposite of the type A students!)

60
ADHD

• Identify behavior problems in specific situations
  and environments
• Hx
• Birthing/delivery events
• Behavior between 18-30 months
• Activity between 2 and 5 years of age
• Aggression, fear, anxiety
• Academic difficulty
• Peer problems
• Behavior problems at school
• Problems with authority
• Separation anxiety
• Temper tantrums
• Signs and sxs may be absent during your exam

61
SUGGESTIVE INDICATORS OF ADHD

• Waking slowly (not snapping awake)
• Grouchy in AM
• Difficulty falling asleep at night (73)
• Unexplained irritability (very common)
• Easily frustrated
• Unexplained negativity w/wo depression (common)
• Verbal or spatial dyslexia (55)

62
ADHD

• Dx
• Review all medications
• Test for learning disabilities
• Test for sensory (hearing) impairment
• Test for petit mal epilepsy
• Evaluate for conduct and mood disorders

63
ADHD

• Tx
• Consider mental health consultation
• Behavioral and psychosocial therapy
• Involve the child, parents, and school
• Controversial (NOT efficacious!)
• Restrict sugar and food additives MVI
• Structured environment
• Regular daily routine
• Rules should be simple, clear, and limited
• Establish firm limits (enforce fairly)
• Avoid overstimulation and excessive fatigue
• Quiet time before bed
• Reward partially successful attempts (i.e.
  stickers)

64
ADHD

• Tx
• Pharmacotherapy
• Adderall, Ritalin, Concerta
• Stimulant
• Most common
• Efficacious in 75-80
• Administer 20-30 minutes a.c.
• Strattera
• SNRI
• Dexedrine Cylert
• Less effective stimulants
• TCAs
• May help with underlying dysthymia/depression

65
Mental retardation

• Significant impairment in measured intelligence
  and adaptive behavior
• Delayed achievement of developmental milestones
  is the cardinal symptom
• Variable progression
• Screen at EVERY encounter!

66
Contributing Factors inMental Retardation

• Preconceptual disorders
• Chromosomal abnormalities
• Early embryonic disruptions/Fetal brain insults
• Infections, teratogens/toxins, placental
  dysfunction
• Perinatal difficulties
• Extreme prematurity, hypoxic-ischemic injury,
  infections, metabolic disorders, intracranial
  hemorrhage
• Postnatal brain insults
• Infections, trauma, asphyxia, metabolic
  disorders, toxins, malnutrition
• Postnatal experiences
• Poverty, parental substance abuse, parental
  psychopathology, family disorganization
• Idiopathic
• Congenital malformations

67
Atypical Physical Features of Mental Retardation

• Head micro-/macrocrania
• Hair double whorl, friable, sparse
• Eyes microphthalmia, micro-/macrotelorism,
  coloboma, nystagmus, outward slant, Brushfield
  spots
• Ears abnormal helix
• Nose flattened bridge, upturned nares
• Face - length of philtrum, hypoplasia of jaw
• Teeth abnormal enamelogenesis/odontogenesis
• Mouth inverted V-shape of upper lip
  high-arched palate
• Hands Feet short 4th/5th MC, abnormal
  fingers, clinodactyly, transverse palmar crease
• Genitalia ambiguous, micropenis, large
  testicles
• Skin café-au-lait spots, depigmented nevi

68
Mental Retardation

• Dx requires IQ testing and deficits in 2 of the
  following adaptive skills (DDS II)
• Communication
• Self-care skills
• Social skills
• Home living
• Community use
• Self-direction
• Health and safety
• Functional academics
• Leisure
• Work

69
Mental Retardation(Lab Studies)

• Chromosomal karyotype
• Serum
• Amino acids
• Uric acid
• Lead, Zinc, Copper
• Lactate and Pyruvate
• Urine
• Mucopolysaccharides
• Reducing substances
• Ketoacids
• Vanilmandelic acid
• Plasma
• Ammonia
• Long-chain fatty acids
• WBC lysosomal enzyme
• Viral titers
• Skin Bx

70
Mental Retardation(Additional Studies)

• Skin Bx
• EEG
• Seizure disorder
• Receptive language impairment
• CT or MRI
• Progressive enlargement of head
• Tuberous sclerosis
• Gross malformation of the brain
• Focal seizures
• Suspected intracranial mass

71
Mental Retardation

• Tx
• Multidimensional
• Individualized
• Multidisciplinary
• Community resources
• Counseling
• Prevention
• Management

72
Cerebral Palsy

• Group of motor disorders
• Caused by damage to the motor areas
• Location/extent of damage determines the Sxs
• May occur any time from fetal life through
  infancy
• Results from Measles infection, radiation, oxygen
  deprivation, or hydrocephalus
• NOT progressive
• Irreversible
• Most appear mentally retarded
• May be deaf or partially blind

73
Depression

• Adolescence is a time of increased emotions
  mood swings
• Existence of depression in children is
  controversial
• Can only be sad when they lack the ability to
  string together hypothetical thoughts about the
  future
• This ability develops in adolescence
• Comorbidity is present in 70 of children
• Prevalence
• 2xF M
• 1 of preschool-age children
• 1-9 of school-age children
• 4-8 of adolescents

74
Depression

• Who is at risk?
• Family history of depression
• Persistence of symptoms
• 3 consecutive hours
• 3 times per week
• Ample evidence of genetic basis
• Low functional levels of norepinephrine and
  serotonin
• Learning theorists feel depression is learned
  from environment due to lack of reinforcers

75
Risk Factors forChildhood Depression

• Academic difficulties
• Family dysfunction
• Family history of mood/personality disorders
• Family history of alcoholism
• ADHD
• Low self-esteem
• Low socioeconomic status
• Poor coping mechanisms
• Severe life events
• Uncertainty regarding sexual orientation

76
Medical/Psychiatric Etiologies

• ADHD
• Addisons disease
• Adjustment disorder
• Anemia
• Anxiety disorder
• Asthma
• Bereavement
• Bipolar disorder
• Diabetes
• Electrolyte imbalance

• Epilepsy
• Hypo-/Hyperkalemia
• Hyperthyroidism
• Lead intoxication
• Mononucleosis
• Post concussion syndrome
• SLE
• Vitamin deficiency
• Wilsons disease

77
Signs Symptoms of Depression in School-age
Children

• Sad expressions
• Irritability
• Cry easily
• Withdraw from play
• Eating and sleeping disturbances
• 50 present with anxiety symptoms
• 20-30 have behavior problems
• May last for 6mos
• Risk for later relapses

78
Depression

• Signs symptoms
• Lethargy
• Sleep disturbance
• Feeling of worthlessness
• Difficulty concentrating
• Appetite changes
• Poor grades
• Truancy
• ETOH or drug use
• Prone to accidents
• Psychosomatic complaints

79
Clinical Manifestations of Depression (5 stages)

• Normal depressive mood swings
• Acute depressive reactions
• Usually after a death or separation
• Healthy grief response
• Monitor activity
• Neurotic depressive disorders
• Lack of resolution of a grief reaction
• Characterized by hopelessness/helplessness
• Interferes with sleep, diet, activity
• Should be monitored by a psychiatrist

80
Clinical Manifestations of Depression (5 stages)

• Masked depression
• Variant of neurotic depressive disorder
• Deals with feelings by denial somatization
• Acting out, truancy, multiple accidents,
  headaches, abdominal pain or substance abuse
• Needs psychiatric management
• Psychotic depressive disorders
• Impaired reality testing, thought distortion,
  delusions
• Guilt
• Needs psychiatric treatment

81
Diagnosing Depression

• Only when other causes of symptoms have been
  excluded
• CBC, CMP, TSH, UDS
• Consider ECG, EEG, and MRI
• Testing/Questionnaires
• Pediatric Symptom Checklist
• Beck Depression Inventory
• Childrens Interview for Psychiatric Syndromes
• Diagnostic Interview for Children Adolescents
• Childrens Depression Inventory

82
Treatment of Depression

• Severely depressed adolescents/adolescents with
  bipolar disorder should always be evaluated for
  medication
• Suicide precautions
• 3rd leading cause of death in 10-19 year olds
• Psychological support
• Milder depressions can sometimes be treated with
  psychotherapy (talk therapy), but research shows
  that "just talking" to a trusted friend or adult
  isn't enough
• Psychotherapy (cognitive therapy) helps identify
  and change depressed thinking patterns and has
  been shown to be as effective as medication for
  some patients

83
Treatment of Depression

• Medications (Mood stabilizers)
• MAOIs
• Used primarily for refractory depression
• Phenelzine sulfate (Nardil)
• Tricyclic antidepressants not effective in
  children
• Selective Serotonin Reuptake Inhibitors (SSRIs)
• Have fewer side effects
• ? Increased risk for suicide in teens
• Fluoxetine (Prozac/Sarafem) only FDA approved
  Rx
• Sertraline (Zoloft) approved for concomitant
  OCD anxiety

84
Try the Depression Quiz
85
Resources

• American Academy of Child and Adolescent
  Psychiatry
• www.aacap.org/
• American Academy of Family Physicians
• www.familydoctor.org
• American Psychiatric Association
• www.psych.org
• American Psychological Association
• www.apa.org
• Depression and Bipolar Support Alliance
• www.dbsalliance.org
• National Alliance for the Mentally Ill
• www.nami.org

86
Anxiety

• Increasing incidence in adolescents and teens
• Increased stress at home and school
• Affects scholastic performance
• Social anxiety/agoraphobia
• Often leads to depression
• May be bipolar
• Dont ignore when developing a treatment plan

87
Adolescent Suicide

• Second leading cause of adolescent death
• 25 suicidal ideation
• 2 threaten or attempt
• 5-45 attempts per completed act
• Attempts F (3x) M
• Success M (3x) F
• Increased incidence in 15-19y.o.
• 90 have a diagnosable psychiatric disorder at
  the time of their death

88
Risk Factors

• Risk factors
• Teen Pregnancy
• History of physical/sexual abuse
• Being adopted
• Being homosexual, bisexual, or unsure
• Witnessing or being a victim of violence
• Contributing factors
• Alcohol/drug abuse
• Depression
• Availability of firearms
• Increased mobility
• Preoccupation with death
• Personal exposure to suicide

89
Adolescent Suicide

• Hx
• Detail the 48-72 hours prior to the threat
• Determine the degree of premeditation
• Current frame of mind/mood
• Firearms are now the most frequent method of
  suicide for men and women of all ages, including
  boys and girls aged 10 to 14 years.

90
Adolescent Suicide

• Methods
• Adolescents
• Firearms
• CO poisoning
• Medication overdose
• Preadolescents
• Jumping
• Poisoning
• Hanging
• Stabbing
• Running into traffic

91
Adolescent Suicide

• Clinical manifestations
• Previous suicide attempts
• Depression
• 1st degree relative with suicidal history
• Feelings of hopelessness/worthlessness/shame/guilt
  
• Preoccupation with death/dying
• Feelings of revenge/anger/hostility
• Parents with marital difficulties
• History of child abuse
• Family alcohol/drug abuse

92
Adolescent Suicide

• Tx
• ALL THREATS/ATTEMPTS SERIOUS!!!
• AVOID SARCASM!!!
• Dont dare, kid or belittle them
• Contract with the patient
• Notify parents
• Watch how family friends respond to the patient
• Psych consult is mandatory
• Schedule a next day follow-up appointment
• Admit for 2-3 days of observation

93
Adolescent Suicide

• After care planning
• Physiologically stable
• Mood controlled
• Temperament controlled
• Appreciates seriousness of the act
• Precipitating events resolved
• Positive support group available
• Note any continued ideation
• Risk for subsequent attempt appears greatest 6-12
  months after the previous attempt

94
Summary

• Colic is a symptom complex characterized by
  paroxysmal abdominal pain and severe crying
• Sudden onset of loud, continuous crying 3
  hours/day and 3 days/week
• Usually occurs in p.m. and persists for several
  hours
• Diagnosis of exclusion with no consistent
  treatment
• Patients with eating disorders present with vague
  complaints
• Anorexia nervosa is defined an intense fear of
  weight gain and a significant misinterpretation
  of body shape
• Bulimia nervosa is defined as binge eating
  combined with inappropriate ways to prevent
  weight gain
• Childhood obesity is associated with numerous
  secondary health problems

95
Summary

• Night terrors usually affect pre-school children
• Cause arousal from Stage 4 (non-REM) sleep
• Confused, frightened disoriented
• Sleepwalking occurs in 10-15 of school-aged
  children and is associated with nocturnal
  enuresis
• Enuresis involves involuntary discharge of urine
  after bladder control has been established
• Attempt to determine probable etiology
• Counsel parents and child!
• Dyslexia is characterized by achievement below
  expectancy in reading and spelling ONLY!
• ADHD is primarily a disorder of cognitive
  impairment characterized by poor ability to stay
  on task, motor overactivity, and impulsivity
• ADHD must be differentiated from a learning
  disability and conduct disorder

96
Summary

• Delayed achievement of developmental milestones
  is the cardinal symptom of mental retardation
• Comorbidity is present in 70 of children with
  depression
• Severely depressed adolescents/adolescents with
  bipolar disorder should always be evaluated for
  medication
• Suicide is the second leading cause of adolescent
  death
• ALL SUICIDE THREATS or ATTEMPTS ARE SERIOUS!!!