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Lecture 76: Child and Adolescent Psychiatry
Nervous System Part III
54
Medical
Professional
03/07/2011

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Term
Describe the initial psychiatric diagnosis of a child.
Definition
uncertainty as child still evolving

**Psychiatric disorders in process of developing may be less “differentiated” than the final form

ex. Depressed children may show increased irritability instead of sadness and boredom instead of anhedonia
Term
What do the anterior and posterior branch of the vagus nerve do?
Definition
anterior - parasympathetic

posterior - fight, flight, or freeze
**allows deep, intimate communication btw individuals
Term
window of tolerance
Definition
optimal arousal zone
Term
optimal arousal zone (3)
Definition
arousal fluctuates in respnose to environemntal cues and organism's internal state (fatigue, hunger, etc.)

sympathetic/parasympathetic balance

people w/wider window can cope w/greater extremes of arousal and can process complex and stimulating info more readily
Term
optimal functioning in window of tolerance (optimal arousal zone)
Definition
threshold should be high enough to tolerate the stimulation from the environment and within, yet low enough to allow us to perveive subtle changes and novelty in the environment and ourselves
Term
most commonly diagnosed psychiatric disorder of childhood
Definition
ADHD (high comorbidity)
Term
Children w/ADHD frequently experience what?
Definition
peer rejection-->leads to self esteem problems and adaptive coping
Term
3 core symptoms clusters of ADHD (according to DSM-IV-TR 2000)
Definition
hyperactivity, inattention, impulsivity

**must last >6 mo for dx
Term
Describe the impact of ADHD on socialization.
Definition
behaviors bcome stigmatizing-->child excluded from games, groups, etc.-->influences her viewpt on herself-->compensatory behaviors

**Young child who is not treated has much higher chance of not being in social groups, unable to hold a job, more divorces, etc.solution is medication as early as possible
Term
comorbidities of ADHD
Definition
-ODD or CD: 50%
-Learning Disabilities: 20 – 60%
-Anxiety Disorder: 25 – 33%
-Major Depression: 3 – 75%
-Bipolar Disorder: 10 - 20% of clinical samples.
Term
ADHD pathophysiology
Definition
hypodopaminergic state - current meds increase DA concentration in prefrontal cortex

**dopamine most affects nucleus accumbens (pleasure center)
Term
distinctive feature of major depression NOT seen in ADHD
Definition
anehedonia, sleep/appepite disturbance
Term
distinctive feature of bipolar NOT seen in ADHD
Definition
delusions
Term
distinctive feature of generalized anxiety NOT seen in ADHD
Definition
EXAGGERATED apprehension and worry
Term
hyperactivity and inattentiveness: child vs adult
Definition
hyperactivity tends to diminish and changes to inner restlessness in adults

inattentiveness very persistent and intractable
Term
3 Txs for ADHD
Definition
medication, parental guidance/counseling, psychoeducational interventions
Term
1st line ADHD Medication Tx
Definition
methylphenidate (Ritalin), dextroamphetamine (dexadrine), amphetamine salts (adderall), atomoxetine (strattera - ONLY 1 that does NOT target nucleus accumbens, just pre-frontal cortex)
Term
When can neuroleptics be helpful in ADHD?
Definition
for comorbid agitation/agression (in combo w/other meds) - by itself, 3rd line
Term
recent info on neuroanatomy of ADHD pts
Definition
children had significant cortical thinning and decrease in total brain volume - deformations in basal ganglia are attenuated in ADHD subjects treated w/stimulate meds
Term
leading cauase of morbidity in pediatric population
Definition
mood disorders
Term
anxiety
Definition
organism's response to a perceived risk (can lead to cardiovascular disease)
Term
Major Depressive Episode criteria
Definition
either depressed mood or loss of interest and at least four of the following:

weight/appetite changes

insomnia or hypersomnia

psychomotor agitation or retardation

fatigue

feelings of guilt or worthlessness

executive dysfunction

suicidal ideation
Term
symptom duration to diagnose MDD
Definition
>2 weeks
Term
dysthymic disorder time
Definition
>1 yr in children/adolescents

**less severe, more chornic than MDD
Term
adjustment disorder w/depressed mood

1. time
2. clinical
Definition
1. <6 mo = acute, >6 mo = chronic

2. marked, excess distress/impairment in social, academic or occupational functioning

**symptoms usually resolve w/in 6 mo if stressor (or consequences) have terminated - don't medicate unless impairment of functioning
Term
How might MDD present in children and adolescents?
Definition
irritable (as opposed to depressed mood in adults)
Term
anaclitic depression
Definition
presentation of depressive disorders in infants - distress, withdrawal, wt loss, sleep disturbance, failure to thrive, developmental delay
Term
Psychotic symptoms of depressive disorders are more likely to present in which age group?
Definition
adults
Term
suicide attempts and completions
Definition
boys 2x more likely to complete, girls 2-3x more likely to attempt
Term
for every depressive episode you have...
Definition
the more likely it is you'll have another one (bc neuronal pathways becoming wired)-->so treat agressively

**major episode avg = 7-9 mo in child/adolescent
Term
biological factors of depressive disorder etiology
Definition
genetic, dysregulation of central serotonergic and/or noraadrenergic systems, HPA axis dysfunction, hormonal influences
Term
stress diathesis model
Definition
stress-->hopelessness-->depression

**personality factor of depressiv disorder etiology
Term
DDx of depressive disorder for impaired concentration and sleep disturbances (3)
Definition
ADHD, mania, anxiety
Term
psychosocial txs of DDs
Definition
CBT

others: psychoanalysis, supportive psychotherapy, interpersonal therapy
Term
percent of children/adolescents w/MDD having comorbid disorders
Definition
40-70% (most common anxiety then disruptive behavior disorders then substance abuse)
Term
MDD and substance abuse cormobidities
Definition
MDD - more likely to occur after the onset of other psychiatric problems

substance abuse - more likely to occur before MDD and increases risk
Term
pharmacotherapy of MDD (3)
Definition
1. SSRIs 1st line
2. TCAs (more effective but worse side effects)
3. MAOi (when others don't wory - low tyramine diet required, can cause HTN crisis)
Term
MDD maintenance
Definition
continue tx for at least 6 months after symptom remission

taper over several wks
Term
3 core features of anorexia nervosa
Definition
1. <85% ideal body wt for age/ht

2. fear of gaining wt/becoming fat

3. amenorrhea (3 consecutive missed cycles in post menarchal females)

**1 of most difficult disorders to treat
Term
The typical anorexic is...
Definition
"the perfect child" - she's neat, obedient, does cooking around house, etc.
Term
chief discriminating factor btw AN and bulimia nervosa
Definition
bulimia - absence of severe wt loss: >85% ideal body wt
Term
components of bulimia
Definition
binge eating/actions to prevent wt gain

***modeling, cancers, people exposed to pubblic, women in high society, etc. are prone to it
Term
binge eating
Definition
More than an average person would eat in a 2 hour period at least twice weekly for three months

**ass. w/loss of control
Term
With anorexia nervosa, the younger the age of onset...
Definition
the better the prognosis for remission

**both AN and BN 10x more common in females
Term
AN - onset, comorbidity, mortality
Definition
onset - 14-18

high comorbidity w/depression

mortality - 10% die of AN complications, 5% from suicide
**w/in 5 yrs, up to 50% of restricting type develop binge eating, developing BN if wt maintained >85%
Term
BN - onset, mortality
Definition
onset late adolescence

mortality rare
Term
heritability of AN
Definition
70% concordance rate for monozygotic twins, 20% for dizygotic

1st degree relatives - more likely to have AN, increased prevalence of mood disorders
Term
BN heritability
Definition
high concordance monozygotic twins

1st degree relatives - high degree substance abuse/dependence
Term
ANs usually lie and their parents are usually unaware of their eating habits. What are some things to look for that may suggest AN?
Definition
-May wear multiple layers of bulky clothing
-Appear younger than chronological age
-Chronic anorexics appear older than age
-Cachexia and breast atrophy common
-Skin dry and frequent carotenemia
-Bradycardia, hypotension, hypokalemia
-Lanugo
-Dental enamel erosion, chipped teeth
-Vomiting types show Russell’s sign (callus on dorsum of fingers)
-Hypertrophic parotid and maxillary glands
Term
SCOFF questionnaire
Definition
-Do you make yourself Sick because you feel uncomfortably full?
-Do you worry that you have lost Control over what you eat?
-Have you lost more than One stone (14 lb) in a 3 month period? (Obviously, this diagnostic screen originated in the UK)
-Do you believe yourself Fat when others say you are thin?
-Would you say that Food dominates your life?
Term
SCOFF questionnaire (for eating disorders)
Definition
-Do you make yourself Sick because you feel uncomfortably full?
-Do you worry that you have lost Control over what you eat?
-Have you lost more than One stone (14 lb) in a 3 month period? (Obviously, this diagnostic screen originated in the UK)
-Do you believe yourself Fat when others say you are thin?
-Would you say that Food dominates your life?
Term
BN pharm Tx
Definition
fluoxetine

**pharmacotherapy more effective in BN than AN
Term
AN pharm Tx
Definition
fluoxetine - to help maintain wt after normal wt achieved

neuroleptics - combat poor appetite, insomnia, body image disortions
Term
psychosocial Tx AN and BN
Definition
AN - family therapy effective

BN - CBT effective and 1st line when no significant comorbid psychopathology
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