Pediatric Special Needs

What are possible long term sequela from child abuse?

1. 3 x more likely to suffer from depression. 2. 6 x more likely to suffer from depression 3. 13 x more likely to abuse drugs 4. 4 x more likely to contemplate suicide

What is the role of the NP in the evaluation for suicide risk?

1. Assess for risk factors/precipitants/S&S 2. Assess for depression 4. Assess for self-injurious behaviors, passive suicidal wishes, or plan. 5. Perform complete history and physical exam 6. Assess for psychiatric history 7. Ask about weapons in the house/availability of weapons or medications. 8. Referral to a mental health practitioner

What are the differences in obsessions and compulsions?

1. Obsession: Persistent reccuring thoughts, impulses, or images. 2. Compulsions: Repetitive behaviors or mental acts that a person feels driven to perform in order to reduce distress or to prevent some dreaded outcome.

Name the 3 subtypes of ADHD.

1. Predominantly inattentive: >6 symptoms of inattention. 2. Predominantly hyperactive-impulsive: >6 symptoms of hyperactivity-impulsivity 3. Combined: >6 symptoms of inattention and >6 symptoms of hyperactivity-impulsivity.

What are signs and symptoms for suicide?

1. Risk taking behaviors 2. Unusual purchases 3. Giving away favorite possessions 4. Verbal threats 5. Preoccupation with death or depressive topics 6. Writing good-bye letters 7. Antisocial behaviors, depressive symptoms.

What does treatment of Conduct disorder consist of?

1. Rule out comorbid disorders, physical illness, and medication side effects. 2. Treatment is not usually effective. 3. Best option is to treat comorbid conditions (learning disorders/ADHD). 4. Referral to community resources. 5. Sometimes antipsychotics are used for severe childhood behavioral problems.

In order to properly diagnose ODB, the pattern of behavior must be present for at least ___months?

6 months

What is the definition of mania?

Abnormal and persistently elevated, expansive or irritable mood present for at least 1 week.

What class of drugs is used to treat bipolar disorder in the pediatric population?

Atypical antipsychotics: 1st line drug--zyprexa, risperdal, invega, serogque, geodon, abilify.

How is disruptive behavior disorder treated?

Behavioral therapy is the treatment of choice.

Describe possible physical findings seen in children who have been sexually abused.

Bruises on genitalia and buttocks ( typically, no visible scars and heal quickly), STDs, genital lesions/rash/discharge, rectal tissues swelling.

What can be a dangerous side effect of suddenly stopping clonidine?

Can cause rebound hypertension

Of the two subtypes of Conduct Disorder, which has the worse prognosis?

Childhood onset has worse prognosis with higher co-morbidity then adolescent onset. Occurs before age 10. -Repetitive, persistent behavior violating the rights of other, or age appropriate social norms: aggression toward people and animals, destruction of property, deceitfulness or theft, serious violations of rules (school or parental).

Define Attention Deficit Hyperactivity Disorder. What are the diagnostic criteria?

Define: Persistent pattern of inattention, poor concentration, impulsivity, and over activity that exceeds normal developmental variation (Distractibility, impulsivity, hyperactivity). Diagnose criteria: > than 6 symptoms of hyperactivity and impulsivity or >6 symptoms of inattention.

What factors influence Oppositional Defiant Behavior (ODB)?

Difficult temperament, disruption in home or primary care givers, harsh, inconsistent and/or neglectful parenting, history of psychiatric disorders in a parent (genetics), learning disabilities, etc.

Describe possible physical findings seen in children who have been physically abused.

Frequent or unexplained bruises or injuries, marks with characteristic shapes (belt buckles, human bite marks), burns, hair (pathcy areas of alopecia), head trauma, retinal hemorrhages in eyes, vomiting, abdominal distention.

What test should the NP order when a child complains of hallucinations?

Get an EEG--more likely to be seizures

What co-morbid condition is present in 50% of kids with Tourette's disorder?

Half of the children with Tourette's disorder have ADHD.

Define child abuse.

Harm, pain, maltreatment, injury deliberately inflicted on a child.

What are some expected benefits of stimulants?

Improved attention, reduced distractibility, reduced impulsivity, reduced off-task behavior, increased productivity and accuracy of school work.

What must the parents be instructed to watch for in children who are on antidepressants?

Monitor for increased risk of suicidal thinking and behavior (suicide)

What types of fractures are often associated with child abuse?

Most suspicious is distal humerus and femur or proximal tibia. Suspicious fractures: metaphyseal or buckle hand fracture, rib, scapular, vertebral, spiral fractures of the humerus or femur in children <2 years of age.

Describe the different types of child abuse. (neglect, emotional abuse, physical abuse, sexual abuse).

Neglect: Failure to provide for child's basic needs (food, clothes, shelter, supervision) Emotional abuse: Constant criticism, rejection, threats, withholding love, affection, support, or guidance. Physical abuse: Injury resulting from beating, punching, biting, burning, choking, kicking, or shaking. Sexual abuse: Any sexual act committed through coercion or physical force (rape, incest, sodomy).

What are warning signs/red flags of abused children?

Nervousness around adults (no eye contact, no animation, no social smile), aggression towards adults or children, inability to concentrate, abrupt dramatic changes in personality or activities, low self-esteem, poor hygiene, acting out sexually.

When is childhood anxiety abnormal?

Ongoing excessive worrying and nervousness that severely interferes with daily activities of childhood, such as separating from parents, attending school, or making friends. 1. Treatment: SSRI or with Strattera if patient has comorbid ADHD.

What are disadvantages for prescribing stimulants?

Potential for abuse (potential for "performance enhancement" misuse).

What are common precipitants of suicide?

Recurrent or long standing loss, chronic illness, family dysfunction, change in living situation, violence (physical or sexual abuse), pregnancy or STD, ETOH or drug abuse, recent trauma, peer problems, previous attempts, feeling alone, hopeless, rejected.

Should the NP diagnose and treat bipolar disorder (BPD)?

Refer due to difficulty of diagnosing.

What class of antidepressants is used to treat PTSD?

Selective serotonin reuptake inhibitors (SSRIs)

What is the rule of thumb in beginning SSRIs in children?

Start low and titrate slow

When prescribing Lamictal to any patient, why is it important to warn the patient/parents about?

Steven-Johnson syndrome: a rare, serious skin reaction.

What is the first line pharmacologic treatment for ADHD?

Stimulants

How is Strattera (atomoxetine) different from other medications used to treat ADHD?

Strattera is a selective norepinephrine reuptake inhibitor (SNRI)--not a stimulant. Has less potential for abuse, but max response not reached until 4-6 weeks.

What are common characteristics of abusers?

Substance abuse (ETOH, drugs), inability to control anger,increased family stress, social isolation, abuser is/was a victim of abuse/domestic violence, disinterested in caring for their children.

What physiologic symptoms accompany panic disorders?

Symptoms: Shortness of breath, palpitations/chest pain, choking/smothering sensations, fear of "going crazy" or losing control, visual disturbances, hot/cold flashes, headaches, stomach ache, nausea or vomiting.

Atypical antipsychotics are used more frequently for schizophrenia due to the risk of ___with antipsychotics.

Tardive dyskinesia

What are some potential side effects of stimulants?

Upset stomach, loss of appetite, insomnia