Peds Psychiatry

Normal age-specific behavioral development

Strategies and Discipline

Attention Deficit Hyperactivity Disorder (ADHD)

• Def:
  • must be present before the age of 12 years old
  • Hyperactivity, impulsivity, or inattentiveness manifesting prior to age 12 years.
  • Highest in preschoolers
  • decreases with age
  • boys predominate
  • between 18% and 35% of affected children have an additional psychiatric disorder.
  • one of the most heritable psychiatric disorders
  • most often the firstborn son
• Presentation:
  • inattention
  • hyperactivity
  • impulsivity
  • developmentally inappropriate
  • duration of symptoms > 6 months
  • Symptoms must occur in more than one setting (example school and home)
• Management:
  • Stimulants
    • methylphenidate (Ritalin) + amphetamine (Adderall)
    • caution: wt. loss & ↓ growth
  • 2nd line/adjuncts
    
    • antidepressants (guanfacine, clonidine (alpha agonist), imipramine, bupropion, venlafaxine)
  • Behavior modification
    • (structure, routine & appropriate goals), family, educational mgmt.

Adjustment Disorders

• Major Life events:
  • Divorce
  • Death
  • Traumatic events

Adolescent adjustment reactions

Anorexia Nervosa

• Def:
  • BMI < 17 or bodyweight < 85% of ideal body weight.
  • lanugo
  • not menstruated for 5 month
• Types:
  • Restricting type: Patients restrict food intake but do not regularly engage in binge eating or purging behavior; some patients exercise excessively.
    
  • Binge-eating/purging type: Patients regularly binge eat and then induce vomiting and/or misuse laxatives, diuretics, or enemas.
• Presentation:
  • Eat very little
    
  • Exercise to excess
    
  • More withdrawn
    
  • Tend to have obsessive-compulsive traits
  • fine hair on her arms 
• Highest risk:
  • Single, 20-year-old, homosexual male
• Diagnosis:
  • EKG:
    • cardiac arrhythmia
    • low calcium – prolonged qt
• Management:
  • Restore nutritional state
    
  • Hospitalization – if weight is < 75% expected body weight
    
  • Psychotherapy – behavioral therapy
    
  • Pharmacologic – SSRIs; Have added benefit of causing weight gain
  • Menstrual will resume at 90% of ideal body weight

Autism Spectrum Disorder (ASD)

• Def:
  • > 6 symptoms from these categories
    
  • impaired social interaction
    
  • impaired communications
    
  • repetitive stereotyped patterns of behavior & activities
  • (facial expression, gestures)fail to develop peer relationships
    
  • does not seek sharing of interests/enjoyment
    
  • does not seek sharing of interests/enjoyment with others
    
  • lacks reciprocal social/emotional interaction
• Presentation:
  • Impaired communications
    
  • delayed speech
    
  • repetitive language use
    
  • lack of spontaneous, varied play activities
  • Repetitive stereotyped patterns of behavior and activities
    
  • rigid commitment to maintaining routines
    
  • become agitated if the routine is interrupted
    
  • sit in a specific chair, dress in a certain way, eat specific food preoccupation with parts of objects
• NOT associated:
  • normal IQ
• Management:
  • referral for neuropsychological testing, behavioral modification strategies, and medications
  • Refer – Autism specialists
    
  • Speech & language pathologist
    
  • Audiology evaluation, +/- EEG
    
  • Behavioral therapy
  • 2nd gen. antipsychotics (risperidone, aripiprazole) for aggression/hyperactivity, mood lability

Binge Eating

• Def:
  • Recurrent binge eating at least once per week for 3 months
  • Eating, in a discrete period of time (e.g., within any 2-hour period), an amount of food that is definitely larger than what most people would eat in a similar period of time under similar circumstances.
  • A sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating).
• Binge eating episodes associated with three (or more) of the following:
  • Eating rapidly, until uncomfortably full, large amounts when not hungry, alone out of embarrassment
  • Feeling disgusted/depressed/guilty afterward
• Management:
  • Psychotherapy adapted for binge eating disorder
    
  • Self-help treatment
    
  • Pharmacotherapy
    
  • Behavioral weight-loss treatment

Bulimia Nervosa

• Def:
  • Frequent binge eating with or without purging
  • normal weight or even overweight
  • Patients are disturbed by their behavior
    
  • Binging and compensatory behaviors occur at least once a week for 3 months
    
  • self-induced vomiting; misuse of laxatives, diuretics, or other medications; fasting; or excessive exercise.
• On the exam look for these classic physical findings:
  • scars on knuckles
  • swollen parotid glands + dental erosions + normal weight +hypokalemia
  • teeth pitting
• Labs:
  • hypochloremia and hypokalemia.
  • metabolic alkalosis
• Management:
  • Restore nutritional state
    
  • Fluoxetine
    
  • Behavioral/family/group therapy
  • Bupropion is contraindicated

Child Abuse

• Presentation:
  • Burns (doughnut-shaped, stocking-glove, symmetrically round)
  • Bruises or injuries with regular patterns on face, back, buttocks, thighs
  • Internal hemorrhages, abdominal injuries, bite marks, injury with the shape of the instrument used
  • spiral fractures
• Management:
  • Assure the safety of the child, with hospitalization if necessary
  • Contact the social service department prior to discharge of the child

Child abuse-neglect

• allowed to engage in potentially harmful behavior (ie, ETOH consumption)
  a child is unattended; in some states, leaving child < age 13 home alone

Conduct Disorder

• Def:
  • Aggression towards people, animals, and property. Deceit and rule violation.
  • lack of empathy
  • It is often seen as the precursor to antisocial personality disorder, which is per definition not diagnosed until the individual is 18 years old.
• Presentation:
  • A repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate societal norms or rules are violated
• Management:
  • Psychotherapy:
    
  • Cognitive-behavioral therapy
    
  • Family therapy
    
  • parent management training (PMT)

Depression

Generalized anxiety disorder (GAD)

• Def:
  • persistent and excessive worry for 6 months
  • worry which they cannot control for the last year
  • sleep disturbances, difficulty concentrating, and irritability
  • apprehensive expectation
  • difficult to control the worry.
  • Restlessness or feeling keyed up or on edge.
  • Difficulty concentrating or mind going blank.
  • Sleep disturbance (difficulty falling or staying asleep, or restless, unsatisfying sleep).
  • muscle tension
  • association of the anxiety with depression
  • worry out of proportion to the likelihood or impact of feared events
  • awakening with apprehension and unrealistic concern about future misfortune
  • young and middle-aged women
• Management:
  • cognitive-behavioral therapy+
    
  • SSRIs: Paroxetine (Paxil) and escitalopram (Lexapro); SNRIs: Venlafaxine (Effexor)
    
  • Buspirone-Can be used as an adjunct to SSRIs
    
  • Benzodiazepines
    
  • Used in the interim until SSRI response is seen

Major depressive disorder

• Def:
  • 5 or more SIEGECAPS for≥ 2 weeks nearly every day and at least one of the symptoms is depressed mood or anhedonia
    
  • SIGECAPS
    
  • Sadness
    
  • Interest/anhedonia
    
  • Guilt
    
  • Energy
    
  • Concentration
    
  • Appetite
    
  • Psychomotor activity
    
  • Suicidal
• Management:
  • SSRIs are the first-line treatment
    
  • Full medication effect is complete in 4-6 weeks.

Oppositional Defiant Disorder (ODD)

• Def:
  • A pattern of angry/irritable mood, argumentative/defiant behavior, or vindictiveness lasting at least 6 months as evidenced by at least four symptoms from any of the following categories, and exhibited during interaction with at least one individual who is not a sibling.
  • more common in boys than in girls. Children with mood disorders, conduct disorder, and ADHD are susceptible to
  • not aggressive towards people or animals, do not destroy property and do not show a pattern of theft or deceit
• Presentation:
  • Frequent temper tantrums
    
  • Arguments with adults and authority figures.
    
  • Does not conform to rules and regulation
    
  • Intentional exasperation of others
    
  • Easily annoyed by others.
    
  • Revenge-seeking & vindictiveness
    
  • Angry attitude
    
  • Harsh and unkin
• Management:
  • Psychotherapy: is aimed at helping the child learn to express and control anger in more appropriate ways.
  • Cognitive-behavioral therapy aims to reshape the child’s thinking (cognition) to improve problem-solving skills, anger management, moral reasoning skills, and impulse control.
  • Family therapy may be used to help improve family interactions and communication among family members. Peer group therapy might also be helpful
  • Pharmacotherapy to control ODD include mood stabilizers, antipsychotics, and stimulants.
  • Other drugs seen in studies include haloperidol, thioridazine, and methylphenidate which also is effective in treating ADHD, as it is a common comorbidity.

Panic

ACUTE panic attack

• Peak:
  • 10 mins
• Management:
  • benzo
    
  • alprazolam (Xanax)

Panic disorder

• Def:
  • recurrent, unexpected panic attacks + avoidant behavior.
    
• Presentation:
  • Palpitations, chest pain, sweating, SOB
• Management:
  • SSRIs: Paroxetine (Paxil), Sertraline (Zoloft), Fluoxetine (Prozac) +CBT desensitization
    
  • Benzodiazepines: for acute attacks (watch for abuse)

Persistent depressive disorder (dysthymia)

• Def:
  • chronic depression for two years or more

Phobia

• Presentation:
  • symptoms begin 10-15 minutes prior to the stress event
    
  • flying, blood, social situations, spiders
• Management:
  • Exposure therapy (first line), teach to relax and try to understand/overcome the fear
    SSRI + CBT
    
  • Benzodiazepines (i.e prior to flying)

Agoraphobia

• Def:
  • an anxiety disorder characterized by marked fear and avoidance of being alone in a place from which escape might be difficult or embarrassing

Premenstrual dysphoric disorder (PMDD)

• Def:
  • Repeated episodes of significant depression and related symptoms during the week before menstruation
• Management:
  • SSRIs are first-line treatment (fluoxetine, sertraline, paroxetine, escitalopram) and can be used continuously or instituted the week prior to menses.
  • Birth control, low-dose estrogen, and diuretics may also be beneficial.
  • SNRIs such as venlafaxine may also be effective in women with predominantly psychological symptoms.
  • Gonadotropin-releasing hormone (GnRH) – SEs include accelerated bone loss and vasomotor symptoms

School Problems

Seasonal affective disorder

• Def:
  • winter blues

Shaken baby syndrome

• Def:
  • A life-threatening injury that occurs when an infant is forcefully shaken back and forth, a motion that ruptures blood vessels in the brain and breaks neural connections.

Substance Abuse

Suicidal Ideations

• Def:
  • In all age groups, male deaths by _ outnumber female deaths 4 to 1
  • About 77% of people who die by suicide were seen by a physician within 1 yr before killing themselves
• Risk factors:
  • Male gender
    
  • Older
    
  • Major depression
    
  • Active substance abuse
    
  • Serious medical problems
    
  • Recent loss (e.g. of employment, relationship, death of family member)
• Management:
  • Consider referral to:
    • emergency services
      
    • Crisis service
    • emergency department

Pharmacology

Serotonin syndrome

• Def:
  • excessive accumulation of serotonin in your body
  • SSRI + MAOI
• Presentation:
  • acute ams seizure restless diaphoresis tremor nv and pain

Death rate

• For children less than 1 year of age, two-thirds of injury deaths were due to suffocation.
  
• Drowning was the leading cause injury death for those 1 to 4 years of age.
  
• For children 5 to 19 years of age, the most injury deaths were due to being an occupant in a motor vehicle traffic crash.