Pediatric mental/neuro health

PTSD symptoms in adolescence

"Acting out," nightmares, insomnia, extreme startling, social withdrawal, fears, anxiety, panic attacks, depression, anger or rage, internalizing, suicidal ideation, impaired concentration, impaired school performance, hypervigilance

Depression categories that occur in childhood and adolescence

(1) MDD (2) dysthymic disorder (3) adjustment disorder with depressed mood

Genetics consultation and referral should be made when

(1) a positive history for an inherited disorder for which the child is at risk (2) physical findings/dysmorphic features on physical exam consistent with a known syndrome (3) known inborn errors of metabolism, and/or (4) noted developmental, growth, and/or structural anomalies.

Biologic theories of depression

(1) impaired neurotransmission (2) endocrine dysfunction (3) biologic rhythm dysfunction.

Factors that consistently influence severity of PTSD response

(1) severity of the trauma exposure (2) parental distress related to the trauma (3) temporal proximity to the event.

Non-stimulant medications

-Atomoxetine - for children >6yo, results can be seen in up to 6 wks of regular use. 24 hr coverage. Do not discontinue abruptly. Report dark urine, flulike illness, fatigue, abdominal pain, or nausea. May increase suicidal ideation. Immediate care needed if there is any change in mood. Contrainidicated with SI, psychosis, mania, tachyarrhythmias or HTN. - Extended-release guanfacine (Intuniv), and extended-release clonidine (kapvay) - for children 6yo or older. Improves impulsivity, Clonidine for sleep. 1-2 wks to see effects.

ADHD history

-Attention: Paying attention, sustaining attention, listening, following through, organization, reluctant to engage in activities that need sustained attention, hyperfocusing on activities of interest, loses things, forgetful, ability to follow three or four step commands -Activity: Fidgets, leaves seat, runs or climbs when inappropriate, has difficulty with quiet games, talks excessively, has problems waiting turn, interrupts, "on the go."

Subtypes of MDD

-Atypical depression -Seasonal affective disorder -Premenstrual dysphoric disorder

Depression management

-CBT (group or individual) -Family therapy or psychoeducation -Medications: SSRIs

Warning signs of suicide

-Changes in behavior (Accident prone or risk taking, Drug and alcohol abuse, Physical violence toward self, others, or animals, Loss of appetite, Sudden alienation from family, friends, coworkers, Worsening performance at work or school, Putting personal affairs in order, Loss of interest in personal appearance, Disposal of possessions, Writing letters, notes, or poems with suicidal content; talking about suicide, Buying a gun or other weapon) -Changes in mood (Expressions of hopelessness or impending doom, Explosive rage, Dramatic swings in affect, Crying spells, Sleep disorders, Talking about suicide). -Changes in thinking (Preoccupation with death, Difficulty concentrating, Irrational speech, Hearing voices, seeing visions, Sudden interest (or loss of interest) in religion) -Major life changes (Death of a family member or friend (especially by suicide), Separation or divorce, Public humiliation or failure, Serious illness or trauma, Loss of financial security, Recent relationship loss (e.g., first love)).

Assessment of pediatric patient with ADHD

-Interviewing the parent and youth, physical examination, standardized ADHD assessment scales from several different sources (parents, caregivers, teachers, child care programs, and/or sports coaches) A complete physical examination should be done with a focus on the following: • Vital signs—weight, height, body mass index (BMI), blood pressure, pulse, and head circumference in young children • Vision and hearing screening • General observation of child's behavior (may or may not present with ADHD symptoms in the clinical setting); observations of parent-child interaction • General—dysmorphic stigmata suggestive of genetic syndrome or prenatal exposure to drugs or alcohol • Skin—café au lait spots; signs of abuse • Ear, nose, and throat (ENT)—signs of past recurring otitis media (scarring of tympanic membranes), signs of respiratory allergies, enlarged tonsils, sleep apnea • Cardiovascular—heart sounds and rhythm, murmur, pulses • Neurologic—general screening examination—mental status, speech and language, motor skills, and general cognition and mental process as appropriate for age • Screening for iron deficiency, lead, and thyroid dysfunction, if indicated

Severity level 2 ASD Requiring substantial support

-Marked deficits in verbal and nonverbal social communication skills; social impairments apparent even with supports in place; limited initiation of social interactions; reduced or abnormal responses to social overtures from others. For example, a person who speaks simple sentences, whose interaction is limited to narrow special interests, and who has markedly odd nonverbal communication. -Inflexibility of behavior, difficulty coping with change, or other restricted/repetitive behaviors appear frequently enough to be obvious to the casual observer and interfere with functioning in a variety of contexts. Distress and/or difficulty changing focus or action.

Eating disorder red flags

-Reads diet books or clips dieting articles -Visits pro-anorexia or bulimia websites (pro Anna or pro Mia) -Intense focus on diet or regular dieting -Sudden desire to be a vegetarian -Sudden picky eating -Visits bathroom regularly during or after meals -Showers multiple times a day -Skips meals because "I ate at school" or other place away from home. -Large amounts of missing food.

PTSD management

-Referral to a pediatric behavioral health specialist, -report to social service agencies is essential for children younger than 18 years who have witnessed or experienced violence. -Psychotherapy **most important -eye movement desensitization and reprocessing therapy (EMDR) - not much evidence. -medication use not well supported in children -b-blockers may decrease somatic symptoms. SSRIs for anxiety/depression. -Crisis intervention for child and parents.

Severity level 3 ASD Requiring very substantial support

-Severe deficits in verbal and nonverbal social communication skills cause severe impairments in functioning; very limited initiation of social interactions; and minimal response to social overtures. For example, a person with few words of intelligible speech who rarely initiates interaction and, when he or she does, makes unusual approaches to meet needs only and responds to only very direct social approaches. -Inflexibility of behavior, extreme difficulty coping with change, or other restricted/repetitive behaviors markedly interfere with functioning in all spheres. Great distress/difficulty changing focus or action.

tests for SAD

-Spielberger State-Trait Anxiety Inventory for Children (STAIC): 20-item, self-report scale useful with children 9 to 12 years old; it can also be used with high reading-skill younger children and low reading-skill adolescents. -The Screen for Child Anxiety Related Disorders (SCARED) is a 41-item self-report scale in the public domain for use in 8- to 18-year-olds.

What to monitor for with use of SSRIs

-Suicide ideations -activation and mania sx: educate parents to monitor for decreased impulse control, marked elevated mood, acting out, fearlessness, and risk taking.

Severity level 1 ASD Requiring support

-Without supports in place, deficits in social communication cause noticeable impairments. Difficulty initiating social interactions, and clear examples of atypical or unsuccessful response to social overtures of others. May appear to have decreased interest in social interactions. For example, a person who is able to speak in full sentences and engages in communication but whose to-and-fro conversation with others fails, and whose attempts to make friends are odd and typically unsuccessful. -Inflexibility of behavior causes significant interference with functioning in one or more contexts. Difficulty switching between activities. Problems of organization and planning hamper independence.

Beck with Wiedemann syndrome developmental cues

-normal development -articulation issues

bipolar disorder management

-referral to a child behavioral provider. -mood stabilizers: lithium, along or in combination with anti seizure medication (valproate, divalproex), and atypical antipsychotics (risperidone) -individual and/or family psychotherapy. -goals: minimizing comorbidities, enhancing problem-solving and communication skills, and reducing negative self-thoughts. stress reduction, healthy diet, exercise, and good sleep hygiene.

Common manifestations of SAD

-school refusal -comorbid depression -sleep problems -impaired social interactions

Pharmacologic management ADHD

-stimulants most effective medication, but 3 non stimulants (one selective norepinephrine-reuptake inhibitor and two α2-adrenergic agonists) are also efficacious.

Diagnostic studies for eating disorders

-to assess levels of electrolyte imbalance and malnutrition and to rule out other causes of weight los and amenorrhea. -CBC -serum electrolytes -fasting glucose -thyroid studies -liver function testing -follicle-stimulating hormone (FSH) -Lutenizing hormone (LH) -urinalysis -electrocardiogram -bone density

Follow up for ADHD

-within 2 to 3 weeks of medication treatment change and monthly until all is stable to assess for core symptoms changes. -Regular reassessment of the child's core symptoms and functioning should occur every 3 to 6 months if stable with feedback from the family, the school, and anyone else involved. -Asses for functionality. -Monitor height, weight, blood pressure, sleep, appetite, and the development of any significant symptoms such as aggression or tics, cardiac changes. -If there is a decision to take the child off medication, there should be close follow-up during the first 4 weeks.

SCOFF questionnaire

1. Do you make yourself Sick because you feel uncomfortably full? 2. Do you worry that you have lost Control over what you eat? 3. Have you lost Over 10 pounds in the last 3 months? 4. Do you believe you are Fat when others say you are thin? 5. Would you say Food dominates your life?

Home-based homework support for children with ADHD

1. Provide a quiet location where work will be done with minimal distractions. Set up a work station equipped with necessary materials. 2. Establish a homework time as early as possible to prevent the child from being too tired, but allow a break after school. 3. Establish a homework plan: Review assignments and make a schedule for completion, breaking into small, manageable pieces. 4. Help the child to get started. Monitor without taking over. Praise effort; do not insist on perfection. 5. Use a timer to help with time management. Structure time for breaks as often as every 15 min if needed. Encourage movement during breaks. 6. Permit time for editing so the child does not lose points due to editing errors. Help to study for tests. 7. Provide incentives to help motivation. 8. Identify another student to contact for clarification.

PTSD diagnosis

1. The child repeatedly re-experiences a set of symptoms from each of the three following categories: • Recurrent and intrusive memories of the trauma • Nightmares of monsters or threats to self or others or distressing dreams about a specific event • Distress caused by cues that symbolize or resemble an aspect of the trauma, including physiologic reactivity 2. The child demonstrates three of the following symptoms, reflecting avoidance of stimuli associated with the traumatic event(s) and numbing of general responsiveness. These symptoms must not have been present before the trauma: • Avoidance of reminders of the trauma • Efforts to avoid thoughts, feelings, or conversations linked to the trauma • Amnesia for an important aspect of the trauma • Detachment or estrangement from others • Emotional constriction (restricted range of affect) • Diminished interest in or participation in usual activities • A sense of a foreshortened future 3. Two persistent symptoms of increased arousal must be new to the child, present for at least 1 month, and cause clinically important distress or negatively affect functioning. These symptoms include the following: • Sleep disturbances • Hypervigilance • Difficulty concentrating • Exaggerated startle response • Agitated or disorganized behavior • Irritability or angry outbursts, extreme fussiness or tantrums

weight gain rate during referring for eating disorders

1.1 lbs (0.5 kg) per week.

Most common onset of symptoms for bipolar disorder occurs at what ages?

15-19

Criteria for ADHD (Inattention)

6 (or more) of the following symptoms have persisted at least 6 months to a degree that is inconsistent with developmental level and that negatively impacts directly on social and academic/occupational activities: For older adolescents and adults (age 17 and older), at least five symptoms are required. a. Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or during other activities (e.g., overlooks or misses details, work is inaccurate) b. Often has difficulty sustaining attention in tasks or play activities (e.g., has difficulty remaining focused during lectures, conversations, or lengthy reading. c. Often does not seem to listen when spoken to directly (e.g., mind seems elsewhere, even in the absence of any obvious distraction. d. Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (e.g., starts tasks but quickly loses focus and is easily sidetracked). e. Often has difficulty organizing tasks and activities (e.g., difficulty managing sequential tasks; difficulty keeping materials and belongings in order; messy, disorganized work; has poor time management; fails to meet deadlines). f. Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (e.g., schoolwork or homework; for older adolescents and adults, preparing reports, completing forms, reviewing lengthy papers). g. Often loses things necessary for tasks or activities (e.g., school materials, pencils, books, tools, wallets, keys, paperwork, eyeglasses, mobile telephones). h. Is often easily distracted by extraneous stimuli (for older adolescents and adults, may include unrelated thoughts). i. Is forgetful in daily activities (e.g., doing chores, running errands; for older adolescents and adults, may include unrelated thoughts).

Half of all motor tics begin by age

7

half of all vocal tics begin by age

9

Additional criteria for ADHD

A. A persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development, as characterized by inattention and/or hyperactivity/impulsivity B. Several inattentive or hyperactive-impulsive symptoms were present prior to age 12 years. C. Several inattentive or hyperactive-impulsive symptoms are present in two or more settings (e.g., at home, school, or work; with friends or relatives: in other activities). D. There is clear evidence that the symptoms interfere with, or reduce the quality of, scial, academic, or occupational functioning. E. The symptoms do not occur exclusively during the course of schizophrenia or another psychotic disorder and are not better explained by another mental disorder (e.g., mood disorder, anxiety disorder, personality disorder, substance intoxication or withdrawl).

Diagnostic criteria for ASD

A. Persistent deficits in social communication and social interaction across multiple contexts, as manifested by the following currently or by history (examples are illustrative, not exhaustive, see text): -1. Deficits in social-emotional reciprocity -2. Deficits in nonverbal communicative behaviors used for social interaction -3. Deficits in developing, maintaining, and understanding relationships. Specify current severity: Severity is based on social communication impairments and restricted, repetitive patterns of behavior B. Restricted, repetitive patterns of behaviour, interests, or activities, as manifested by at least two of the following, currently or by history (examples are illustrative, not exhaustive, see text): -1. Stereotyped or repetitive movements, use of objects, or speech -2. Insistence on sameness, inflexible adherence to routines, or ritualized patterns of verbal or nonverbal behaviour -3. Highly restricted, fixated interests that are abnormal in intensity or focus -4. Hyper- or hyporeactivity to sensory input or unusual interest in sensory aspects of the environment Specify current severity: Severity is based on social communication impairments and restricted, repetitive patterns of behavior (See Table 30.10) C. Symptoms must be present in the early developmental period (but may not become fully manifest until social demands exceed limited capacities, or may be masked by learned strategies in later life). D. Symptoms cause clinically significant impairment in social, occupational, or other important areas of current functioning. E. These disturbances are not better explained by intellectual disability (intellectual developmental disorder) or global developmental delay. Intellectual disability and autism spectrum disorder frequently co-occur; to make comorbid diagnoses of autism spectrum disorder and intellectual disability, social communication should be below that expected for a general developmental level. Note: Individuals with a well-established DSM-IV diagnosis of autistic disorder, Asperger's disorder, or pervasive developmental disorder not otherwise specified should be given the diagnosis of autism spectrum disorder. Individuals who have marked deficits in social communication, but whose symptoms do not otherwise meet criteria for autism spectrum disorder, should be evaluated for social (pragmatic) communication disorder. Specify if: With or without accompanying intellectual impairment With or without accompanying language impairment Associated with a known medical or genetic conditions or environmental factor Associated with another neurodevelopmental, mental, or behavioural disorder With catatonia (refer to the criteria for catatonia associated with another mental disorder)

ADHD combined type

ADHD in which both hyperactivity and inattention are problems The majority of ADHD cases.

Children with which comorbidity may be vulnerable to bipolar disorder?

ADHD. It may be that ADHD is a misdiagnosed early sign of the mania to come. Tx for ADHD with psychostimulants or antidepressants may precipitate a manic episode.

Only FDA-approved stimulant for children as young as 3 years old

Adderall

Classroom accommodation for impulse control assistance in child with ADHD

Allow for freedom of movement as much as possible (e.g., classroom helper). Never punish the child by taking away physical education, recess, or other physical activity outlets. Teach the child to monitor quality of work before turning it in.

Mental disorder with highest mortality rate

Anorexia 5 year rate is 15-20%

MOst important aspect of ASD management

Behavioral management

OCD management

CBT first line for mild to moderate Pharmacologic interventions for moderate to severe (SSRIs for effective)

Children with psychosis

Child behavioral health specialist may add antipsychotics like risperidone or olanzapine to the therapeutic drug plan.

Clinical findings in school age children with ADS

Children with autism often lack reciprocal friendships, have ritualistic behaviors, and continue with language, social, and behavioral problems. Transitions between places and activities can be difficult.

Comprehensive diagnostic assessment for ASD

Comprehensive diagnostic assessment should be done by a multidisciplinary team, ideally at a specialty center, and address core symptoms, cognition, language, and adaptive, sensory, and motor skills. Specialty assessment includes developmental, behavioral, and IQ testing; audiologic evaluation; and genetic testing with microarray. Neuroimaging, EEG, and metabolic testing may be done if indicated by examination and history.

Language red flags for ASD

Delayed speech and language skills (no babbling or gesturing by 12 months old; no single words by 16 months old; no two-word [not echolalic] phrases by 24 months old) Repeats words or phrases over and over (echolalia) Monotone intonation, rhythm, rate, pitch, volume, and quality of sound issues Speech that sounds scripted Difficulty with conversation where each person adds information Parental concern about hearing due to lack of response Loss of language at any age

Management of eating disorders

Difficult. need referral to behavioral health specialists multifaceted approach with emphasis on nutritional rehabilitation, pharmacotherapeutics (antidepressants, atypical antipsychotics), individual, family, and group therapy

Classroom accommodation for productivity assistance in child with ADHD

Divide worksheets into sections. Reduce the amount of homework and written classwork. Modify the number of math problems to be completed. Provide test modification—quiet location and extra time. Use assistive technology—word processor, calculator, audio books, and note-taker pen.

Screening questions for OCD

Do you wash yourself or clean more than most people? Do you feel the need to check or double-check things often? Do you have thoughts that bother you that you would like to get rid of but can't? Do you find yourself spending a lot of time doing things (brushing teeth, getting dressed)? Does it bother you when things are not lined up or are not in order? Do these problems bother you?

When is suicidal risk greater in depressive disorders?

During the first 4 weeks of an episode. (Emergence period)

Classroom accommodation for organizational skill assistance in child with ADHD

Establish a daily checklist of tasks. Use a daily planner. List homework assignments with due date and needed resources. Divide notebook into three sections: work to be completed, work completed, and work to be saved. Color code class material to help organize. Follow up on homework not turned in. Allow extra time for gathering necessary items, packing backpack, and so on. Provide an extra set of textbooks for use at home. Teach strategies for time management and basic study skills. Develop preview and planning skills.

How often to increase dose in SSRIs to improve response in depression?

Every2-4 wks as long as significant side effects are absent.

key feature of PTSD diagnosis

Exposure to trauma

Patterns of behavior or interests red flags in ASD

Gets upset by minor changes Has obsessive interests Flaps hands, rocks body, or spins in circles Unusual reactions to the way things sound, smell, taste, look, or feel Self-injurious behaviors (head-banging, biting, pinching)

Classroom accommodation for written expression assistance in child with ADHD

Give extra time to complete written tests and assignments. Provide help with handwriting. Allow child to dictate reports and take tests orally. Reduce the quantity of written work required. Grade papers on content rather than untidy work, spelling errors, or poor handwriting.

Marfan syndrome primary care issues

Heritable, multisystem disorder of connective tissue • Monitor growth using syndrome-specific growth chart; Peak growth velocity occurs up to 2 years earlier. • Excessive linear growth of long (tubular) bones; typically taller than predicted for their family; altered arm-span to height ratio; bones of hands/fingers are elongated, but palm is normal, giving rise to positive thumb/wrist signs. • Monitor for orthopedic conditions/problems, including joint laxity, protrusion acetabuli, scoliosis, thoracic kyphosis, pes planus; pectus abnormalities are common. • Many clinical features are age-dependent (e.g., ectopia lentis, aortic dilation, dural ectasia, protrusion acetabuli). • Cardiac screening with echocardiogram continues throughout life; age on onset/rate of progression of aortic dilation is highly variable; β-blockers are often prescribed; decongestants and psychostimulants should be used with caution. • Ongoing BP monitoring (hypertension). • Participation in contact/competitive sports, as well as isometric exercise is restricted; aerobic activities in moderation. • Annual ophthalmology screen; myopia is common and progresses rapidly; ectopia lentis is a hallmark feature; increased risk of retinal detachment, glaucoma, and early cataract formation. • Dural ectasia often presents with postural hypotension/low-pressure headaches. • Increased risk of spontaneous pneumothorax, reduced pulmonary reserve, and sleep apnea. • Stretch marks are common across lower back, inguinal and axillary regions (perpendicular to axes of growth). • Hernias/recurrent hernias and incisional hernias are common.

When to consider SSRI use in patients with depression

If no improvement in 6-8 with CBT.

When to refer patients with depression to child behavioral health provider?

If they meed criteria for moderate to severe depression, and if there is no improvement within 2 months of SSRI use, or if there is worsening of symptoms while on medication.

Social red flags for ASD

Lack of social smile and eye contact at 2-3 months of age Lack of joint attention (shared spontaneous enjoyment) around 9 months Does not respond to his or her name by 12 months old Does not follow a point to a picture or object and look back at pointer by 12 months Does not point at objects to show interest (pointing at an airplane flying over) by 14 months old Does not pretend (feed a doll) by 18 months old Avoids eye contact and wants to be alone Trouble understanding other people's feelings or talking about their own feelings Gives unrelated answers to questions Loss of social abilities at any age

Clinical findings in early childhood ADS

Language delays in early childhood (especially expressive), trouble modulating voice. Language delays include lack of meaningful speech, decreased gestures, and gaze disturbances. Socially, the child exhibits detachment, decreased eye contact, a lack of reciprocity or initiating conversation, lack of fear, poor creative play, invasion of others' space, preference to be alone, and lack of social awareness. Persistent and insistent behaviors, excessive temper tantrums, repetitive movements, and a preference to line, stack, or spin toys occur. The child may have precocious or average development of rote memory skills but often without concept comprehension.

School and teacher history for patient with ADHD

Level of performance (below potential for achievement) Tends to miss the point of conversations and activities Often does things the hard way in absence of established routines Information from school about child's strengths, weaknesses, difficulties, academic management of issues.

Fragile X Syndrome Primary care issues

Most commonly inherited form of mental retardation. • Any male child with developmental delay, borderline intellectual ability, or mental retardation should be tested as early physical recognition is difficult as clinical phenotype (males) can be subtle prior to puberty. • Cognitive deficits can be moderate to severe. • Often experience delayed toilet training, enuresis. • Hypersensitivity to sensory stimuli is common. Avoid excessive stimulation (e.g., large crowds, loud noises); provide earphones. • Monitor for behavior problems, including ADHD, emotional lability, irritability, and temper tantrums. • Increased risk for seizure activity, decreasing at adolescence. • Language delay is common, especially conversational speech. • Infants may have congenital hip dysplasia and/or clubfoot, feeding difficulties/GER, hypotonia, and irritability. • Increased incidence of recurrent/chronic OM, sinusitis. Audiologic evaluation annually for conductive hearing loss. • Orthopedic referral for connective tissue dysplasia issues (e.g. pes planus, hypermobile joints, scoliosis). • Ophthalmologic evaluation annually for strabismus, refractive errors. • Increased risk of inguinal hernia(s). • Macro-orchidism begins ∼9 years of age. Adolescent growth spurt is less. • Increased risk for autism, hypertension, mitral valve prolapse. • Females have wider phenotypic variability; however, premature ovarian failure (menopause) is common.

Behavior management for Patient with ADHD

Not as powerful as medication in reducing ADHD core symptoms. Used alone for children younger than 6, symptoms are mild, and/or DSM criteria are not met. Used paired with medication if poor response to medication alone, there are psychosocial stressors or coexisting conditions, or when the parents desire it. -Three essential components include: (1) increasing positive parent-child interactions, (2) practicing different scenarios with the child, and (3) learning time-out/disciplinary consistency. -As a child with ADHD approaches middle school, high school, and college age, new approaches are needed as the child assumes more control. Counseling may be needed.

PANDAS clinical findings

OCD like symptoms plus enuresis, emotional irritability, aggression, separation anxiety, and nightmares.

Family education for families with children with ADHD

On developmental concerns, academic performance issues, learning disabilities, medical diagnoses, social concerns, family issues and stressors, and associated coexisting mental health diagnoses. Identify family's and patient's strengths and build on those. Help parents understand the diagnosis complexity, to deal with feelings of shock, confusion or guilt, if present. Ongoing support is important. Include key family members in collaborative decision-making, striving to become more aware of the community and cultural values of patients.

PCP role in ADHD

PCPs act as care coordinators with strong family-school partnerships. The plan of care focuses on the areas of functional impairment: academic achievement; relationships—parent, peer, sibling, and adult authority; social skills—sports and recreational participation; and behavior and emotional regulation. A key element is having three specific, measurable short-term target goals at a time from the areas that are most impaired, incorporating the child's strengths and resiliency

Clinical findings depression in school age children

Parents and teachers may report decreased mood, impaired concentration, inattention, irritability, fluctuating mood, temper tantrums, social withdrawal, somatic complaints, agitation, separation anxiety, or behavioral problems -males: more externalizing symptoms (aggression, acting out, anger, hyperactivity, recklessness, school absences, poor school performance) -females: more internalizing symptoms (somatic, feelings of sadness, boredom, lack of interest in playing with friends) -eating or sleeping disturbances, enuresis, or encopresis.

Clinical findings in infants with ADS

Passive, non-engaging, quiet, floppy or difficult, colicky, stiff, have poor eye contact, or fail to respond to name or gestures.

Who requires immediate psychiatric evaluation? (depression)

Patients with acute suicidal intent that includes a plan, psychosis, risk of abuse, and unstable behavior. Cumulative suicidal risks—prior suicidal behavior or attempts, depression, and alcohol, tobacco, or drug abuse/dependence.

PANDAS

Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal infections

Follow up frequency for patients with depression needing medications.

Phone call to parents/patient within 3 days and see the patient weekly until stable with the first 4 weeks of treatment being critical. Once stable, maintenance visits can occur at 3-month intervals.

Classroom accommodation for social relationship assistance in child with ADHD

Provide feedback about behavior involving other children. Make sure other children do not believe that the child is doing less or is allowed unacceptable behavior; change the rules for all children if necessary.

GAD management for older children or adolescents

Refer to a pediatric mental health therapist for treatment of symptoms using mindfulness, psychodynamic therapy, or cognitive-behavioral therapy (CBT). Pharmacologic intervention in combination with psychotherapy.

Classroom accommodation for self-esteem assistance in child with ADHD

Reward progress. Encourage performance in areas of child's strength. Avoid humiliation. Give hand signals only the child can see as private reminders of appropriate behavior.

Pediatric anxiety disorder triad

SAD GAD and social anxiety often appear in the same individual and have similar life courses and treatments.

Classroom accommodation for memory and attention issues in ADHD child

Seat the child close to the teacher away from heavy traffic areas (e.g., doorways). Keep oral instructions brief with repetitions; avoid multiple commands. Provide written directions—broken down or simplified if needed. "Walk" the child through assignments to be sure they are understood. Break tasks and homework into small tasks. Use visual aids, hands-on, and experiential teaching methods rather than strict lecture style. Teach active reading with underlining and active listening with note taking. Provide remedial help in small sessions. Teach sub vocalization (saying words in your head while reading) to aid memorizing. Establish a signal that reminds the child to focus and return to task. Allow nondistracting motor activity during tasks requiring concentration (e.g., squeezing a ball or fingering Velcro to replace pencil tapping). Allow earplugs for auditory processing issues.

Turner syndrome primary care issues

Sex chromosome disorder • Monitor growth using syndrome-specific growth chart; short stature is expected; GH treatment typically begun early (∼4-5 years of age). • Nonverbal (e.g., math) learning disabilities are common. • Annual hearing exam; recurrent otitis media; progressive midfrequency sensorineural hearing loss. • Ongoing vision assessment; strabismus. • Early onset osteo-penia/-porosis; vitamin D supplementation; appropriate estrogen therapy; exercise. • Monitor BP (hypertension). • Annual thyroid screen (hypo-/hyperthyroidism); monitor for celiac disease. • Ongoing assessment for celiac disease (tissue transglutaminase immunoglobulin A). • Careful early monitoring for kyphosis, scoliosis, lordosis. • Increased risk of hyperlipidemia; cardiac defects (e.g., aortic root dilatation; bicuspid aortic value; coarctation of aorta) and renal anomalies (e.g., horseshoe kidney, double collecting system, increased urinary tract infection [UTI]). • Supplemental estrogen therapy for sexual development and preservation of bone mineral density (late childhood/early adolescence). • Tendency to form keloids.

ADHD predominantly hyperactive-impulsive type

Significant number of hyperactivity/impulsivity symptoms identified, but not significant number in inattention category. Accounts for the fewest ADHD cases.

ADHD Predominantly Inattentive Type

Significant number of inattentive symptoms identified, but not significant number in hyperactivity/impulsivity. Accounts for about one-third of ADHD cases.

Clinical findings in adolescents with ADS

Similar to school age children. Rote learning is possible, but comprehension lags. High-functioning autistic children do well in regular classrooms and mildly affected persons can be academically successful but have social relationship problems.

Criteria for ADHD (Hyperactivity/impulsivity)

Six or more of the following symptoms have persisted for at least 6 months to a degree that is inconsistent with developmental level that negatively impacts directly on social and academic/occupational activities: For older adolescents and adults (age 17 and older), at least five symptoms are required. a. Often fidgets with or taps hands or feet or squirms in seat. b. Often leaves seat in situations when remaining seated is expected (e.g., leaves his or her place in the classroom, in the office or other workplace, or in other situations that require remaining in place). c. Often runs about or climbs in situations where it is inappropriate. (Note: In adolescents or adults, may be limited to feeling restless. d. Often unable to play or engage in leisure activities quietly. e. Is often "on the go" acting as If "driven by a motor" (e.g., is unable to be or uncomfortable with being still for extended time, as in restaurants, meetings; may be experienced by others as being restless or difficult to keep up with). f. Often talks excessively. g. Often blurts out an answer before a question has been completed (e.g., completes people's sentences; cannot wait turn in conversation). h. Often has difficulty waiting his or her turn (e.g., while waiting in line). i. Often interrupts or intrudes on others (e.g., butts into conversations, games, or activities; may start using other people's things without asking or receiving permission; for adolescents and adults, may intrude into or take over what others are doing).

PTSD symptoms in school age

Sleep problems, nightmares, developmental regression, repetitive themes in play, social withdrawal, may have partial amnesia of events, new onset anxiety or fears, panic attacks, impaired concentration, impaired school performance, avoidance symptoms or hypervigilance, somatic complaints

When to refer for OCD

Symptom severity increasing, signs of psychosis, or suicidality, or who fail to respond to SSRIs

Screening for ASD

The AAP recommends screening for autism at both 18 and 24 months, as a negative screen at 18 months may be abnormal at 24 months. The Modified Checklist for Autism in Toddlers revised with follow-up (M-CHAT-R/F) is the most used tool.

Motor and verbal tics that press for more than one year are called

Tourette syndrome

DH diagnostic tools

Vanderbilt ADHD Scales, the ADHD Rating Scale IV, Conner Parent and Teacher Rating Scales, and the Child Attention Profile -should be completed by individuals who know the youth, and at lest from two different domains.

PCP responsibilities for patients with depression,

Vigilant follow-up regarding weapons in the house. Referral to community resources, such as hotlines, and to identify an emergency plan for the family should the patient become actively suicidal, psychotic, or a danger to others.

Signs that indicate need for treatment in eating disorders

_regularly fasts or skips meals -Stops eating with family or friends -Misses 2 or more periods during weight loss -Reports being eating -Reports purging -Parents find laxatives or diet pills -Excessive exercise -Refuses to eat non-diet foods -Refuses to eat meals prepared by others -Extreme calorie counting or portion controls

Separation anxiety disorder (SAD)

abnormal reaction to real, impending, or imagined separation from major attachment figures, home, or familiar surroundings.

children and adolescents with psychotic depression have a greater incidence of

adverse long-term outcomes, resistance to psychopharmacotherapy, and a much higher risk of developing bipolar depression.

Risk factors for ADHD

alcohol and tobacco use during pregnancy, premature and low birth weight, exposure to environmental toxins (lead) in pregnancy or in early childhood, brain injury, and ACEs. Maternal inflammation during pregnancy is theorized to cause reduced infant brain circuitry thus affecting key pathways connecting the executive hub and deeper emotional processing regions and affecting working memory.

PANDAS management

antibiotic treatment Corticosteroids immunoglobulin plasma exchange refer to specialist

Medications in depressed children that may precipitate mania and the onset of bipolar illness?

antidepressants

Most common comorbidity with depression

anxiety

Poor long-term outcomes in depression patients

associated with severe or frequent disease, and in patients with significant family dysfunction, low socioeconomic status, and history of abuse or family strife.

MDD diagnosis

at least 2 weeks of depressed mood or loss of interest and at least four additional symptoms of depression. The symptoms cause considerable distress and impairment in social and academic functioning and cannot be caused by bereavement.

GAD management for preschool children and toddlers

behavioral and family interventions CBT with caregiver component

Multidisciplinary care for children with ASD

behavioral-developmental pediatrician or nurse, an applied behavior analysis (ABA) therapist, gastroenterologist or allergist, a dietician, and/or speech and occupational therapists. Care of the child with ASD is tailored to disease severity and can be complex. Ensure that the following therapies are in place: ABA therapy supervised by a Board Certified Behavior Analyst (BCBA), speech therapy, occupational therapy with a sensory processing focus (modulation for self-regulating and soothing) and assistance with play and self-help skills, and physical therapy if needed. Referring the child for dental care with a provider who is familiar with ASD issues is helpful

ADHD or behavior disorder are often early symptoms of

bipolar disorder

psychiatric disorder with the highest risk for suicide

bipolar disorder

common simple tics

blinking, twitching of hands or limbs, shoulder shrugging, tongue thrusting, or squinting.

dysthymic disorder

characterized by depressed or irritable mood for the majority of days in the past 2 years that is less intense but more chronic than major depressive episodes.

Atypical depression

characterized by hypersomnia, increased appetite, psychomotor retardation, and weight gain.

How can depression be differentiated from the irritability and inattention of ADHD?

children with MDD are not usually impulsive, and they typically have a normal attention span before the onset of symptoms.

Autism Spectrum Disorder (ASD)

complex neurodevelopmental disorder that affects communication and behavior beginning in the first two years of life. Causes impairment in social interaction with additional impairment in communication and restrictive, repetitive, stereotyped patterns of behaviors, interests, and activities.

complex motor tics

complicated movements like jumping or a series of simple tics

Adverse effects of stimulants

decreased appetite, weight loss, insomnia, stomachache, and headache. With time, these symptoms often resolve but must be monitored. If they persist, decreasing the dose, switching the medication, or adding a medication may help. Emotional lability and irritability indicates that medication dose needs adjustment, or diagnosis needs to be revisited.

In bipolar disorder adolescents may have this as their initial symptom.

depression

PCP role in eating disorders

detection and early intervention, case coordination, and monitoring for complications.

Assess all these areas when diagnosing ADHD

developmental mastery—school, peers, family life, sports, and recreational activities. it is important to assess the onset, duration, the settings where impairment is present, and the nature and degree of symptoms and functional impairment

Pharmacologic therapy ASD

do not benefit from stimulant medications unless they also suffer from an attention deficit (about half do); they are more sensitive to stimulants so the "start low, go slow" approach should be adhered to. Alpha agonist (guanfacine or clonidine) or norepinephrine reuptake inhibitors (atomoxetine) may prove more effective. Atypical antipsychotics, risperidone or aripiprazole, are FDA approved for irritability and explosive behaviors but are not routinely recommended. Fluoxetine, an SSRI, may be used in lower doses for anxiety, phobias, and compulsions, and requires monitoring for agitation, increased energy, and poor sleep. Citalopram is not recommended. About one-quarter of autistic children also need anticonvulsants for seizures. Disproven treatments include antifungal medication, chelation, secretin, and immunotherapy

Assessment for PTSD

do not use prompting or leading questions. Instead ask questions about whether someone has invaded the child's privacy, how it happened, and how the injuries came to be. Assessment should ascertain that a trauma has occurred, the nature of the trauma, and the consequent symptom pattern. Trauma mneumonic .Trauma—known traumatic experience .Re-experience—includes flashbacks and nightmares .Avoidance—avoids stimuli associated with the event .Unable to function .Month or longer .Arousal—is hypervigilant, has sleep disturbances, concentration difficulties, or an exaggerated startle response.

PANDAS diagnostic criteria

dramatic onset of OCD or tic disorder in children between 3 years old and puberty shortly following GABHS infection and symptom exacerbation.

MDD

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

Pharmacological therapy for older children and adolescents

elective serotonin reuptake inhibitors (SSRIs), especially sertraline, and fluoxetine; serotonin and norepinephrine reuptake inhibitors (SNRIs), especially venlafaxine and duloxetine; and other medications like buspirone.

Activation (depression)

elevated energy without mood change.

Anxiety disorder in childhood

emerge in the preschool years bit it is not usually diagnosed until middle childhood.

If child or adolescent has depression and manifests severe symptoms of ADHD (extreme temper outburst and mood changes)

evaluation by a child behavioral health specialist with experience in bipolar disorder is needed.

Environmental factors that modulate genetics predisposing to ADS are

extreme prematurity, meconium aspiration, breech delivery, and low 5-minute Apgar scores; maternal medications (valproic acid and thalidomide) and advanced parental age; autoimmune and toxin exposure.

Clinical findings depression in infants and young children

failure to thrive, speech and motor delays, repetitive self-soothing behaviors, withdrawal from social interaction, poor attachment, and loss of developmental skills. Infants may not respond to extra efforts to soothe or engage them.

PTSD symptoms in infancy

feeding problems, failure to thrive, sleep problems, irritability

Inpatient management for eating disorders

for medical instability (electrolyte or cardiovascular instability), psychosis or self-destructive behavior, and failure to improve with outpatient therapy.

When to refer children for anxiety?

for moderate to sever anxiety. hospitalization if in immediate danger.

ASD is associated with these genetic disorders

fragile X syndrome (most common), neurofibromatosis, tuberous sclerosis, Angelman syndrome, and Rett syndrome

SAD age of onset

from 5 to 16 years old and the mean age for clinical presentation is 9 years old

separation anxiety normal at this ages

from about 7 months old through the preschool years

Anxiety risk factors peds

genetics temperamental disposition for behavioral inhibition and/or shyness social environment or life circumstances

diagnostic lab work for tic disorders

hemoglobin, ferritin, renal function, hepatic function, thyroid function, and substance use

Referral for ADHD

if things don't go as expected, or there is poor medication response or emergent comorbidities. At times, transitions are overwhelming and referral to behavioral health for coping skills training helps.

mild depression

impact in daily life, but affected individuals are still able to function and complete normal tasks although doing so requires a lot of energy because of lack of motivation.

ADHD symptoms

inattention, hyperactivity, and impulsivity occurring at a developmentally inappropriate level observed in at least two settings (home, school, or work) with clear evidence of clinical impairment in social, academic, or occupational functioning.

Severe depression

increased agitation, psychosis, and suicidality and will often demonstrate all the depression symptoms. All adolescents with a minimum of five symptoms who have clear suicidality and a plan or recent attempt, who are psychotic, have a first-degree relative with bipolar disorder, or who have significant impairment including being unable to leave the home are considered to have this.

Common classroom techniques for child with ADHD

increased structure with the use of behavior contracts with goals and reinforcement; token economy (earning or losing points that can be exchanged for privileges or items); creating a periodic behavior report card (e.g., daily or weekly progress notes); and/or study or organizational skills training. Other considerations are brain/energy breaks (a set time to stretch, get up and walk around), secret signals to indicate need for a break, and allowing a child not to be still (bouncy balls, standing or pacing while working). Peer intervention strategies, either in groups or as a pair, help reduce inappropriate or disruptive behavior.

simple motor tics

involve a single muscle group

Untreated children with ADHD can struggle with

learning, social relationships, self-management and self-esteem, employment (lower socioeconomic status, higher unemployment rates), more traffic violations and higher motor vehicle accident rates, difficult family interactions including marital discord and divorce, and increased risk of substance abuse, depression, and anxiety.

Prevalence ASD

males more affected. More common in non-Hispanic White children.

ADHD is more common in _______ than _______, and _________ tend to have more problems with inattention.

males, females; females

Clinical findings depression in toddlers and preschoolers

may lack energy, be too eager to please others, be excessively or unusually clingy or whiney, and have developmentally inappropriate problems with separation. Preschoolers may present with sad or grouchy mood, lack of pleasure in play or activity, poor appetite and weight loss, sleep problems, low energy and activity levels, low self-esteem, or increased death or suicide play or talk.

First-line medications for uncomplicated ADHD

methylphenidate and amphetamine compounds Children with inattentive presentation often respond well to lower doses, whereas children with hyperactive presentation have a more positive response at moderate to high doses. -long-acting dosing is preferred, short-acting doses may be chosen for initial dosing or if dosage titration or side effects of concern.

Risk factors of eating disorders

middle to high socioeconomic status, divorced families, chronic disease (e.g., diabetes mellitus, cystic fibrosis, depression, obesity, and substance abuse), recent weight loss in a previously obese person, personality disorders (e.g., borderline, narcissistic, and antisocial), strong will, and history of child abuse. Parents who have a weight or fitness focus, are substance abusers, have high achievement expectations, who comment on their child's physical appearance, have difficulty expressing emotions, or who are overprotective or enmeshed with their children.

management of tics

mild: no tx required moderate to severe: comprehensive behavioral intervention for tics (CBIT), SSRIs, atypical antipsychotics (risperidone), and antihypertensives (clonidine). Use of elastic bands to discourage behavior, positive reinforcement.

bipolar disorder manic episodes in adolescents

more likely to include psychotic features and may be associated with school truancy, school failure, substance use, or antisocial behavior.

seasonal affective disorder (SAD)

most common during the fall and winter months when there is less daylight.

FDA recommends against this medication in children and adolescents (depression)

paroxetine due to risk for suicide.

GAD management for preschoolers specifically

play therapy

Clinical findings ASD

problems with social interactions, communication, and language skills; unusual ways of relating to people, objects, and events; abnormal responses to sensory stimuli, usually sound; and restricted, repetitive, or stereotypical behaviors and echolalia (meaningless repetition of others' speech). Development is uneven (dissociated), with occasional talent in a limited area, such as music or mathematics, coupled with severe deficits in other areas. Many autistic children have other impairments, such as sleep problems, gastrointestinal problems (diarrhea, constipation, and abdominal pain), and irritability. Co-occurring diagnoses of ID (32% to 60%), ADHD (33%), anxiety or depression, disruptive disorders (aggression, tantrums, and self-injury), and seizures (20% to 25%) are common

PCP role in genetic disorders

provide primary care, anticipate areas of medical vulnerability, and advocate for the prevention of any secondary disability. Find a genetic specialist or counselor; to initiate referrals with screening pedigrees, medical records, and other information; and to evaluate the family's understanding of the need for a referral to genetic professionals. Once the family has had genetic counseling, the child's PCPs should reinforce genetic counseling information, assess the family's need for return genetic counseling visits, refer to local specialists and support services when appropriate, and advocate for the child/family within the community as well as within the healthcare system.

contraindications to stimulants

psychosis or any previous untoward reactions to stimulant medication. Those with heart problems or increased BP or problematic HR. Patient with preexisting tic disorder or with family history of Tourerre syndrome.

referring syndrome

rare, potentially life-threatening condition that occurs in the first days of enteral or parenteral feeding and results in severe fluid and electrolyte imbalance. Symptoms include confusion, severe irritability, organ dysfunction, and seizures.

Bipolar from childhood may lead to

severe disease, to be hospitalized frequently, and to have a less favorable life course

kinefelter syndrome primary care issues

sex chromosome disorder • Monitor growth and development, especially speech. • Monitor for scoliosis. • Annual thyroid screen. • Caution—delayed puberty/gynecomastia/low testosterone, increased risk for autoimmune disorders, breast cancer.

PTSD symptoms in preschool age

sleep problems, nightmares, developmental regression, aggression, extreme temper tantrums, anxiety symptoms, sudden worsening of fears, irritability, avoidance symptoms.

patients with ADHD may present with

struggles in the classroom, difficulties with peers, or trouble regulating their behavior or emotions.

Acute stress disorder

symptom pattern occurring and resolving within a 4 week period after the traumatic event.

first priority in school-age children regarding anxiety

symptom relief

Clinical findings depression in adolescents

symptoms similar to those of adults. impulsivity, fatigue, hopelessness, antisocial behavior, substance use, restlessness, grouchiness, aggression, hypersexuality, and problems with family members or at school. Social withdrawal, manifested as shyness, boredom, or a lack of motivation, is common.

When assessing adolescents for depression

talk directly to them

children with developmental disorders have greater risk of developing _____ than their nonaffected peers.

tics

first priority in infants and young children regarding anxiety

treating the source of the problem

other common tic disorders include

trichotillomania, bruxism (tooth grinding), skin pulling, and nail biting.

What to do if treatment at the highest tolerated dose of one stint group does not help?

try a medication from other group or a different medication from the same group.

Adjustment disorder with depressed mood

typically occurs within 3 months after a major life stressor, involves less-severe symptoms, and is relatively mild and brief.

Marfan syndrome developmental cues

usually within normal range

verbal tics

vocalizations or pushing air through the nose, grunting sounds, clearing throat.

moderate depression

what began as a decreased interest in engaging in activities becomes a complete lack of interest, and affected individuals often express concern about their inability to function and complete tasks.

premenstrual dysphoric disorder (PMDD)

within a week of menstruation and lasts until a few days after menstruation.

Common physical findings that may indicate an eating disorder

• Altered growth • Parotid gland enlargement • Fluid retention, facial edema • Thin body type, low body temperature • Hypotension, bradycardia, orthostatic hypotension, shallow respirations • Dental enamel erosion, dental caries • Russell sign (e.g., knuckle cuts/calluses/abrasions from inducing vomiting) • Thinning hair, alopecia, decreased deep tendon reflexes • Abdominal distention, altered bowel sounds • Lanugo, dry skin • Muscle atrophy • Mental torpor

Friends and activities for patient with ADHD

• Areas of strength should be developed (music, sports, computer) rather than always focusing on areas of weakness. Camps, clubs, and appropriate work provide avenues for development of skills and new friendships. • Activities of the child's choosing in areas of strength or developmentally appropriate work can help build peer relationships and self-esteem. • Friendships may come more easily if structure is provided (going to a movie or a sporting event) and the time frame is consistent with what the child can handle. • Musical training facilitates development and maintenance of certain executive functioning skills that may be helpful to children with ADHD.

Home management for pt with ADHD

• Calm home environmental with clear day and night routines. • Homework support. Monitor for mental fatigue. • Exercise: Aerobic exercise. Scheduling daily time to be active and expend energy, especially in the morning before school, is extremely important to help children with ADHD stay regulated. Martial arts, which demand discipline and self-control, are especially useful. • Downtime or senseless fun: Children with ADHD need more time for normal childhood activities, including time to do nothing and daydream. Time in less-structured activities improves self-directed executive function. • Computers: Many children with ADHD love computers; they produce neat results, never criticize, offer second and third chances, can help with spelling and organization, and provide opportunities for relaxation. Keep an open mind to their use to ensure they are not used to the point of social isolation. • Nutrition: Regular mealtimes with normal portion sizes provide healthy eating that provides necessary energy. High caloric foods if nutrition intake is low. • Sleep: Ritualized bedtime routines are important; massage, deep breathing, and relaxation techniques are sometimes helpful. Melatonin (2-6 mg/day), low-dose clonidine, or an antihistamine may be helpful; however, long-term use of these agents is not recommended. • Patience, unconditional love, and support are especially important for children with ADHD, because they face so many challenges getting through their day. Plan a daily "time in" for 15-20 min with undivided parent attention focused on a child-selected activity. • Complementary treatments.

Down syndrome primary care issues

• Careful review of newborn screen for hypothyroidism. Annual and/or systematic screening for hypothyroidism. • Careful review of newborn critical congenital heart disease (CCHD) with ongoing cardiac evaluations. • Monitor growth using syndrome-specific growth chart. • Ongoing ophthalmologic exam for cataracts. • Careful review of newborn hearing screening, followed by ongoing otologic/hearing evaluation. • Monitor for obstructive sleep apnea. • Increased risk for duodenal atresia. • High risk for atlantoaxial instability; if any signs of cervical myelopathy, obtain radiograph, refer to neurosurgery. • Monitor for neurologic conditions (e.g., infantile spasms, seizures, Moyamoya malformation). • Systematic screening for celiac disease (CD). • Increased risk for leukemia.

22q11 deletion syndromes clinical findings

• Congenital heart defect • Palate abnormalities • Facial features: Long tubular nose, crumpled ears, hypertelorism, malar hypoplasia • Hypotonia • Early feeding problems • Constipation • Chronic otitis media/sinusitis • Polydactyly • Vertebral anomalies • Strabismus

Diagnostic criteria for bulimia

• Consuming large quantities of food in a short period of time (within 2 hours) • Loss of control during binge episodes (e.g., cannot control the amount of food they eat or are shocked at amount consumed) • Engaging in repeated behaviors to lose weight, including purging, excessive exercise, or fasting • Bingeing or purging behaviors that occur at least once a week for at least 3 months

Prader-Willi syndrome clinical findings

• Decreased fetal movement/position • Failure to thrive • Short stature • Central obesity • Hypothalamic insufficiency • Strabismus • Myopia/hyperopia • Sleep apnea • Enamel hypoplasia • Scoliosis

Klinefelter Syndrome (XXY) developmental cues

• Delayed expressive language • Shy, withdrawn • Immature for age • ADHD

22q11 deletion syndromes developmental cues

• Developmental disability • Communication disorders, including delayed speech and hypernasality • Psychiatric disorders

SAD clinical findings

• Developmentally inappropriate or excessive anxiety about separations • Unrealistic worry about harm to self or loved ones, or fears about abandonment during periods of separation • Reluctance to sleep alone or sleep away from home • Persistent avoidance of being alone • Nightmares about separation • Physical complaints and signs of distress in anticipation of separation • Social withdrawal during separations • Environmental stress, parental dysfunction, and maternal depression are risk factors especially with panic disorder or agoraphobia, the fear of being outside the home, in crowds, or places they won't be able to easily leave

Things to consider when dosing stimulants

• Dose response is unique to each child/teen and should be adjusted for age, body weight, degree of impairment, and specific symptoms • Begin dosing at the low end and titrate up every 1 to 3 weeks with monitoring for symptom improvement and side effects • The dosing goal is maximum reduction of ADHD core symptoms with minimal side effects • Change to a different medication, the other stimulant group, or a nonstimulant medication if the child is at the maximum dose without adequate response or is having significant side effects • Instruct families to monitor for benefit and adverse effects to identify the lowest effective dose

difficulties in adulthood due to ADHD

• Fewer employment possibilities and higher rates of unemployment • Higher risk of tobacco, drug, and alcohol abuse • Higher risk of motor vehicle accidents • Marital discord and higher divorce rates • Increased incidence of criminal involvement

Fragile x developmental cues

• Intellectual disability • Language delays • Behavioral problems (e.g., anxiety, attention, aggression) • Stereopathies, such as hand-flapping • Autism spectrum disorder

Down syndrome neurodevelopmental cues

• Intellectual/cognitive disability/developmental delays • Hearing loss • Hypotonia (infant)

Neurofibromatosis 1 (NF1) developmental cues

• Learning, speech/language, and motor abilities vary

Common history findings of eating disorders

• Menstrual irregularity • Body dysmorphism • Preoccupation with food; often fixes elaborate meals but does not eat; rituals associated with food • Desire to lose weight and history of dieting • Weight fluctuation or loss • Guilt about eating • Hides eating or lies about having eaten or amount eaten • Social isolation, mood changes, suicidal ideation • Fixed, highly structured schedule; inflexible to change • Cold intolerance, fatigue, myalgias • Constipation, diarrhea, abdominal bloating, gastrointestinal (GI) distress • Sore throat • Dizziness, syncope • Substance abuse, self-harm • Family history of chaos, abuse, sexual abuse

Prader-Willi Syndrome developmental cues

• Motor delays • Poor coordination • Language delays • Mild intellectual disability • Compulsive hyperphagia • Behavioral phenotype: Tantrums, stubborn, rigidity, skin picking, high pain tolerance, ADHD, compulsiveness

difficulties in adolescence due to ADHD

• Needs for special education (high comorbidity with learning and emotional disabilities) • School failure and dropout • Social difficulties with peer relationships • Substance abuse (in untreated ADHD) • High comorbidity with other psychiatric disorders (depression, anxiety, conduct disorder) • High-risk behaviors leading to greater accident rates • Involvement in juvenile criminal activities

Childhood difficulties due to ADHD

• Needs for special education (high comorbidity with learning disabilities) • Grade retention • Classroom behavior management issues • Difficulties with friendships and peer relationships • Behavioral difficulties at home and other settings (child care, sports, after-school programs) • High comorbidity with other childhood psychiatric problems • Associated difficulties (at higher rates than non-ADHD children) with sleep disorders, enuresis, encopresis

Turner Syndrome (XO) neurodevelopmental cues

• Nonverbal learning disabilities • Hearing loss • Strabismus

Beckwith-Wiedemann clinical findings

• Omphalocele or umbilical hernia • Macroglossia; with later onset of malocclusion/maxillary underdevelopment • Facial features: Prominent eyes, nevus flammeus, helical pits, anterior ear lobe creases • Large placenta/long umbilical cord • Hypoglycemia (newborn) • Large at birth (LGA) with increased growth after birth (macrosomia) • Abnormal enlargement of one side of the body/structure (hemi-hyperplasia/ -hypertrophy)

Marfan syndrome clinical findings

• Phenotypic variability, including variable facial features (e.g., long, narrow face, downward slanting eyes, malar hypoplasia, and micrognathia) • Often tall for age, extremities disproportionately long in comparison with trunk; altered arm-span: height ratio • Paucity of muscle mass/fat stores • Aortic root dilatation, aortic tear/rupture, aortic valve prolapse/regurgitation, tricuspid vale prolapsed, mitral valve prolapse/regurgitation • Myopia, ectopia lentis (hallmark), retinal detachment, glaucoma, and early cataract formation • Spontaneous pneumothorax, reduced pulmonary reserve, and obstructive sleep apnea • Skeletal issues, including pectus deformities, scoliosis, thoracic kyphosis, and protrusion acetabuli, pes planus, reduced mobility of elbow, increased laxity of other joints • Stretch marks (lower back, inguinal, axillary regions) • At risk for dural ectasia

Fragile X Syndrome clinical findings

• Prominent forehead, long narrow face, prominent jaw, high-arched palate/dental crowding, protuberant ears develop late childhood/early adolescence • Feeding problems/GER • Strabismus, refractive errors (e.g., hyperopia, astigmatism), nystagmus, ptosis. • Recurrent/chronic OM • Seizures • Short stature • Macroorchidism (puberty) • Connective tissue dysplasia (e.g., velvet-like skin, joint hypermobility especially fingers), pes planus, congenital hip dislocation, clubfoot, scoliosis • Obstructive sleep apnea • Possible in girls

MDD assessment

• Recent life events and losses • Family history of depression or other psychiatric disorders • Family dysfunction • Changes in school performance • Risk-taking behavior, including sexual activity and substance use • Deteriorating relationships with family • Changes in peer relations, especially social withdrawal

Diagnostic criteria for anorexia

• Refusal to maintain body weight at least 85% expected for age and height or failure to gain weight during growth periods so that weight drops below 85% expected • Intense fear of weight gain and "being fat" • Body dysmorphism • Binge eating/purging subtype, which is associated with frequent purging although bingeing episodes are rare

Family support for ADHD tx

• Routines, rules, and family relationships are key. Home should be a safe place where one feels valued. • Family meetings provide opportunity to discuss structure, rewards, and consequences, as well as to plan and problem solve. • Support and advocacy groups help with managing daily problems that come from living with ADHD. • Family therapy or counseling is frequently used short term with specific family situational goals. It is especially helpful if there is aggressive behavior or problems related to anxiety, self-esteem, and depression or if other family members (especially siblings) need psychological assessment or support. • "Coaching" helps a child or adolescent develop difficult skills. Helps with problem solving, time management, organizational skills, and learning strategies (how to be an active learner, learning to learn, and learning how to organize learning). -Calm parenting is very successful for ADHD child.

Angelman Syndrome clinical findings

• Seizures • Global developmental delays • Abnormal gait, arms held high/flexed elbows • Hypotonic trunk with hypertonic limbs (commando crawl) • Feeding/growth problems • Acquired microcephaly

bipolar disorder clinical presentation

• Severe mood changes—extreme irritability or overly elated and silly • Inflated self-esteem or grandiosity—"I am the best in the world at X" • Increased energy and physical agitation • Decreased need for sleep (sleeps few hours or no sleep for days without tiring) *hallmark* • Talkativeness or compulsion to talk; frequent topic changes or cannot be interrupted • Racing thoughts • Distractibility, with attention moving constantly from one thing to another • Increase in goal-directed activity (socially or at school)—get "stuck" on activities and can't stop doing them • Risk-taking behaviors or activities; taking "more dares" • Hypersexuality in talk, thoughts, feelings, or behaviors • Psychosis—visual or auditory hallucinations • Suicidal thoughts and behaviors in 76% of cases and suicidal attempts in 31% of cases

Down syndrome clinical findings

• Short stature • Brachycephaly • Midface hypoplasia with flat nasal bridge • Brushfield spots • Epicanthal folds with upslanting palpebral fissures • Small mouth with protruding tongue • Myopia/cataracts • Small ears/narrow canals • Extra skin at nape of neck • Lax joints (atlantoaxial instability) • Short broad hands/feet/digits • Single palmar crease • Clinodactyly • Exaggerated space/plantar groove between great and second toes • Congenital heart disease • At risk for leukemia, hypothyroidism, Alzheimer disease

Turner Syndrome (XO) clinical findings

• Short stature (for family) • Short neck with webbing and low posterior hair line • Posteriorly rotated ears, narrow canals • Ptosis • Short 4th/5th metacarpals • Short legs • Hyperconvex nails • Cardiac disorders (e.g., bicuspid aortic valve, coarctation of the aorta) • Hip dysplasia, scoliosis, and/or kyphosis • Horseshoe kidney • Chronic OM, with conductive hearing loss • Delayed puberty/infertility

Angelman Syndrome developmental cues

• Speech delay, but adequate receptive language • Intellectual disability • Spontaneous (persistent) social smile/fits of laughter • Hand flapping • Loves water • Abnormal sleep

Klinefelter Syndrome (XXY) clinical findings

• Tall, with long arm span • Dental decay • Delayed puberty • Small penis, cryptorchidism (or small testes) • Gynecomastia • Autoimmune disorders • Skin striae • Scoliosis • Increased risk of malignancies, including male breast cancer

Neurofibromatosis 1 (NF1) clinical findings

• Two or more of the following features are required: • ≥6 café-au-lait spots 5 mm (prepubertal)/15 mm (postpubertal) • ≥2 neurofibromas or 1 plexiform neurofibroma • Axillary/inguinal freckling • Optic glioma • ≥2 Lisch nodules (iris hamartomas) • Associated osseous lesion (e.g., sphenoid wing dysplasia, cortical thickening of cortex in long bones) • First-degree relative with NF1

PTSD criteria

• Witnessing or experiencing a traumatic event(s) that resulted in risk of death or serious injury to oneself or a loved one • Event(s) that resulted in fear, helplessness, recurrent distress, agitation, or irritable behavior (the latter two are part of the diagnostic criteria for children younger than 6 years old) • Symptoms that cause increased arousal, excessive startle, altered mood and emotional response, or intrusive thoughts or recurrent dreams and continued avoidance of reminders of the trauma • Symptoms that last at least 1 month and cause significant impairment in social, cognitive, or school functioning • Acute symptoms that last less than 3 months and chronic symptoms that last more than 3 months

generalized anxiety disorder (GAD) clinical findings

• Worry about future events and/or preoccupation with past behavior • Poor-quality sleep and unexplained fatigue • Irritability and tantrums in young children • Overconcern about competence and marked preoccupation with performance • Significant self-consciousness and unusual need for reassurance • Restlessness, difficulty concentrating • Somatic complaints without a physical basis • Comorbidity with other anxiety disorders, ADHD, or mood disorder