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Flashcards in Child and Adolescent Psych Deck (29)
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1

Cornelia de Lange Syndrome

Chromosome 9q33, lack of pregnancy assoc plasma protein A (PAPPA)
-continuous eyebrow, thin downturning upper lip, microcephaly, short, small hands/feet, small upturned nose, malformed upper limbs, FTT
-severe-profound ID, self injury, stereotypic movements, twirling, language delay, avoids being held

2

Fragile X

-mutation of FMR1 (CGG repeats > 200)
-most common inherited cause of ID (DS most common genetic)
-prominent forehead, long face, prominent jaw, large ears, short
-male- mod to severe ID, female mild ID/LD
-comorbid ADHD, anxiety, OCD-like sx, ASD, irritability/lability

3

FASD

-most common preventable cause of ID
-sentinel facial features: short palpebral fissures, smooth/flat philtre, thin upper lip
-neurodevelopmental domains: motor skills, cognition, language, academic achievement, memory, attention, executive function incl hyperactivity and impulse control, affect regulation, adaptive behaviour/social skills/communication
Diagnosis:
FASD with sentinenel facial features- 3 sentinel facial features AND confirmed/unknown prenatal EtOH exposure And evidence of impairment in 3 domains or microcephaly
FASD w/o sentinel facial features: impairment in 3+ neurodevelopment domains AND confirmation of prenatal EtOH at levels known to be associated with neurodevelopment effects

4

Down Syndrome

-Trisomy 21
-Most common genetic disorder
-short, hypotonia, single transverse palmar crease, epicanthal folds, flat nasal bridge, upward slanting palpebral fissures, small mouth and ears, hearing loss
-frequent otitis media, eye disease , OSA, thyroid disease, neurological disroders
-psychiatric- ASD (<10%), ADHD (>25%), mild-mod ID, stubbornness/oppositional, but severe psychiatric/behavioural problems are rare
-high risk of dementia

5

Prader-Willi

15q11-13
-most common genetic cause of obesity
-hyperplasia, central obesity, small hands/feet, microorchidism, fair hair, almond shaped eyes
-ID: 5% normal, 60% mild 30% moderate ID
-sensitive to medications
-comorbid: ASD, skin picking ++, OCD like sx, high rates of behavioural problems == aggression, tantrum, emotional lability, mood disorders

6

Angelman syndrome

-fair hair, blue eyes, wide smile, thin upper lip, ataxic gait, happy, paroxysmal laugh, sleep problems, love music/water
-90% epilepsy
42% ASD

7

Williams Syndrome

homozygous AD deletion on 7q11.23
-short stature, broad forehead, depressed nasal bridge, wide spaced teeth, elfin like face, sociable
-mild-moderate ID; verbal > visual/spatial,
-medical- renal, CV, thyroid, hypercalcemia, poor vision
-comorbid- anxiety, hyperactivity

8

Turner Syndrome

-XO- X monosomy
-short stature, low set ears, webbed neck, shield chest, cubits values, gonadal dysgenesis
-NOT an important cause of ID, but may have LDs in math or visual spatial skills
-25% have ADHD

9

Velocardiofacial syndrome (DiGeorge)

22q11
-cardiac anomalies, T cell deficits, cleft palate, hypoCa, pharyngeal hypotonia, slender hands/digits
-schizophrenia (25%), LD, ADHD (35-45%) anxiety, BPAD, depression

10

Lesch-Nyan Syndrome

defect in hypoxanthine quinine phospohribosyl transferase
-ataxia, chorea, kidney failure, gout
-severe self biting, aggression, anxiety
-mild-moderate ID

11

Cri du Chat SYndrome

AD hemizygous deletion 5p15.2
-congential heart disease, GI anomalies, infantile cat like cry, epicentral folds, slanting palpebral fissures, broad flat nose, migcrognathia
Severe ID
hyperactivity, stereotypies, self-injury

12

Smith Magenis syndrome

17p11.2 deletion
facial features- broad square face, prominent forehead, deep set up slanting eyes, unibrow, short broad hands, deep hoarse voice, laryngeal abnormabilites
-Moderate ID
comorbid- hyperactive, severe self injury (hand biting, head banging, pulling out nails)

13

ADHD Comorbidities

40% ADHD and ODD
38% ADHD and mood/anxiety disorders
32% ADHD only
14% ADHD and Conduct disorder
10% ADHD and tics
(exam-- ASD no prominent comorbidity)

14

Oppositional Defiant Disorder

A. Pattern of angry/irritable mood, argumentative/defiant behaviour or vindictiveness lasting at least 6 months with evidence of 4 symptoms and exhibited in interactions with at least one person who is not a sibling:
angry irritable mood: often loses temper, is grouchy or easily annoyed, is often angry or resentful
Argumentative/defiant behaviour: often argues with authority figures/adults, actively defies rules or refuses to comply with requests/rules from authority, deliberately annoys others, blames others for mistakes/misbehaviours
Vindictiveness: spiteful or vindictive at least twice in past 6 months
*under 5 yo: sx should be most days for 6 months
*over 5 yo: weekly sx for 6 months
B. behavioural disturbances causes distress to individual OR to others in immediate social context, or impacts negatively on social, educational, occupational, or other important areas of function
C. behaviours are not due to psychosis, substance use, depression or bipolar disorder. Does not meet criteria for DMDD.
specifiers:
Mild- sx are confined to one setting
moderate- sx in at least 2 settings
severe- sx in 3 or more settings

15

Conduct disorder

A. Repetitive and persistent pattern of violating the basic rights of others or age appropriate societal norms/rules with 3/15 for the past 12 months, with 1 in the last 6 months:
-Aggression to people and animals: bullies, threatens or intimidates others, initiates physical fights, has a weapon, physically cruel to people, physically cruel to animals, stolen while confronting a victim, forced sexual activity
-Destruction of property: setting fires, destroying other's property
-Deceitfulness or theft: broken into house/building/car, lies to obtain goods/favors or to avoid obligations, has stolen items of non-trivial value w/o confronting victim
-Serious Violations or Rules: stays out at night < 13yo, run away from home overnight at least 2x while at parents, or once without returning for a lengthy period, truant from school beginning < 13yo
B. Behaviour causes significant impairment in social, academic or occupational function
C. if age 18 or older, antisocial PD criteria not met
specify:
childhood onset- 1 symptom before age 10 yo
adolescent option- no symptoms prior to age 10 yo
unspecified onset-- unknown age of onset
with limited prosocial emotions- persistently displays 2 of the following in multiple settings over 12 months: lack of remorse/guilt, callous (lack of empathy), unconcerned re performance, shallow or deficient affect
mild, moderate or severe (based on symptom severity)

16

Treatment of CD/ODD

-primary prevention: Head Start in at risk communities
-< 8 yo- parent management training-- increase positive interactions, focus on pro-social behaviour, less attention to undesired behaviours
>8yo- multi systemic tx: interventions incl individual (CBT, social skills), parent management training, school supports, peer group, neighbourhood (church, youth group, ?sports teams), pharmacotherapy
-involve school, treat SUDs

17

Pharmacotx for CD/ODD

2015 Cdn Guidelines on Pharmacotx for disruptive and aggressive behaviour in Children and adolescents with ADHD, ODD or CD
Recommend:
*ADHD +/- CD or OD: stimulants improve oppositional behaviour, conduct problems and aggression (strongly recommend); atomoxetine, guanfacine and clonidine have conditional recommendations for oppositional behaviour
*N/low IQ with ODD/CD +/- ADHD: Risperidone has conditional recommendation (mod to large benefit with conduct problems and aggression, but conditional b/c major adverse effects); valproate also has conditional recommendation
Conditionally not recommended-- Quetiapine (adverse SE, with poor quality evidence), Lithium (adverse SE and low quality of evidence)
Strongly NOT recommended- Halloo and Carbamazepine

18

Disruptive mood dysregulation disorder criteria

A. Severe, recurrent temper outburst (verbal or behavioural), out of proportion in intensity/duration to situation.
B. Inconsistent with developmental level
C.> 3x week
D. Mood between is persistently irritable/angry
E. Above symptoms for > 12 months, with no period without ALL sx > 3 months
F. Sx are present in 2-3 of home/school/w peers, and are severe in at least 1 setting
G. diagnosis at greater than 6 yo and before 18 yo
H. Onset of sx before 10 yo
I. No manic/hypomanic sx for > 1 day
J. Behaviour not exclusive during MDE or better explained by another mental disorder (ASD, PTSD, PDD, Separation anxiety) and cannot be diagnosed with ODD (DMDD trumps), intermittent explosive disorder, or bipolar disorder

19

ADHD scales (CADDRA 2018)

Children and adolescents: SNAP IV (parents, children)
Weiss Functional impairment Rating scale parent (WFIRS-P)
CADDRA teacher assessment form
Adolescents: ASRS (adult ADHD self report scale), Wess Functional impairment Rating Scale- self (WFIRS-S)
Adults- ASRS (adult ADHD self report scale), WFIRS-S,
collateral ASRS, if possible SNAP IV on childhood symptoms by parent etc

20

Medical Differential for ADHD

Medical
-hearing/vision impairment
-thyroid dysfunction
-hypoglycemia
-severe anemia
-lead poisoning
-sleep disorders incl OSA
-FASD
-Neurofibromatosis
Medications
-medications with cognitive dollying side effects (eg mood stabilizers)
-medications with psychomotor agitation (eg decongestants, beta-agonists like asthma medication)

21

Treatment of ADHD and comorbid conditions (CADDRA 2018)

ODD- stimulant and non-stimulant tx of ADHD sx, psychosocial treatment (parent management, CBT, or Collaborative and Proactive Solutions) +/- antipsychotics (off label)
CD/Aggression- Stimulant and non-stimulant tx of ADHD sx, especially impulsivity, multi systemic treatment incl parenting/family tx, problem solving skills training, individual therapy and community supports, may also need off-label rx of antipsychotics or mood stabilizers
ASPD- tx each disorder separately-- only impulsive sx of ASPD likely to imrprove with tx of ADHD, may need to use non-stimulants if high risk of SUD or diversion
BPD- no studies; DBT and pharmacotx to target impulsive behaviour and emotional dysregulation; balance need for medications with risk of medication misuse
SUD- most common is cannabis (no evidence that it treats ADHD), generally treat concurrently, preferring medications with lower risk of abuse/diversion incl long acting stimulants and non-stimulants
Anxiety- high comorbidity; treat most impairing condition first; can use stimulants (may need slower titration) and non-stimulants (esp atomoxetine)
MDD-treat most impairing condition first (consider safety with severe depression), often will need both stimulants and antidepressant, consider drug interactions (256- paroxetine and fluoxetine and amphetamines or atomoxetine), bupropion may improve both ADHD and depressive sx
BPAD-stabilize BPAD sx first, small risk that stimulants cause switch to mania, then d/c and destabilize before cautiously trying again
DMDD- research pending. Treat with ADHD meds and psychosocial interventions
OCD- watch for Tic disorders; treat concurrently (no adjustments needed), no evidence that stimulants worsen OCD
Tourette's and Tic disorders- can treat with stimulants, but monitor for worsening tics (although population data indicates that stimulants do not worsen tics, but may in individuals; clonidine/guanfacine XR treat both; atomoxetine can be used if stimulants worsen tics
Eating disorders- higher rates of ADHD in BN, and AN purging type; be wary re use of stimulants for restricting weight; tx may be helpful to manage impulsivity; rule out OSA in obese pt
ASD- prior to DSM V diagnoses were exclusive; can use stimulants, but more sensitive to side effects so start lower and slower, risperidone and aripiprazole (off label) have been used for hyperactivity but has bad side effects, atomoxetine and guanfacine have some evidence

22

CADDRA 2018: Contraindications and precautions all treatments

CI: hypersensitivity/allergy to medication
Precaution: cardiac disease, bipolar disorder, psychosis, pregnancy
Monitor: Height and weight, new mood, anxiety, SUDs, psychotic or manic sx, SI/behaviour, aggressive behaviour, sleep, appetite, irritability/mood swings

23

CADDRA 2018: CI/precautions to stimulants

CI: treatment with MAOi include up to 14 days after discontinuation, narrow angle glaucoma, untreated hyperthyroidism, mod-severe HTN, pheochromocytoma, symptomatic CV disease, hx of mania or psychosis
Precautions: hx of SUD, anxiety, renal impairment, tic disorders, epilepsy, peripheral vasculopathy (incl Reynolds)
Monitor: BP, HR, priapism, growth retardation, peripheral vasculopathy

24

CADDRA 2018: CI/precautions with atomoxetine

CI: tx with MAOi include to 14 days post d/c, narrow angle glaucoma, uncontrolled hyperthyroidism, pheochromocytoma, mod to severe HTN, symptomatic CV disease, severe CV d/o, advanced arteriosclerosis
Caution: asthma, CYP2D6 poor metabolizers, peripheral vasculopathy
Monitor: priapism and urinary retention, signs/sx of liver injury, growth retardation, peripheral vasculopathy

25

CADDRA 2018: CI/precautions with alpha-2 agonists (clonidine, guanfacine)

CI: inability for parents/patients to ensure regular daily dose (risk of rebound HTN if stopped abruptly)
Precaution: hepatic impairment, renal impairment
Monitor: somnolence and sedation, BP, risk of hypotension, bradycardia, syncope, elevated BP/HTN on abrupt d/c, QTc interval (monitor if other meds/risk factors)

26

CADDRA 2018: First line (6-12 yo)/(13-17yo)/(adult)

1st line: long acting psychostimulants
Adderall XR (amphetamine salts) 5mg daily titrated q weekly by 5mg to 30mg/50mg/50mg

Biphentin (methylphenidate) 10-20mg titrated by 5-10mg q weekly to 60mg/80mg/80mg

Concerta (methylphenidate) 18mg titrated up to 72mg/90mg/108mg

Vyvanse (lisdexamphetamine) 20-30mg titrated by 10mg weekly to 60mg/70mg/70mg

27

CADDRA 2018: 2nd line (6-12 yo)/(13-17 yo)/adult

2nd line/adjuncts

Intuniv XR (guanfacine) 1mg titrate by 1mg/week to 4mg daily/ 7mg mono therapy or 4 mg adj/ no indication in adults

Strattera (atomoxetine) 0.5mg/kg/day increase to 0.8mg/kg/day then to 1.2, max 1.4mg/kg/day or 60mg/day// 100mg/day// 100mg/day

short and intermediate acting stimulants:
dextroamphetamine: dexedrine, dexedrine spansules
methamphetamines: Ritalin, ritalin SR

28

Autism Spectrum Disorder DSM V

A. Persistent deficits in social communication and interaction in multiple contacts, for example, deficits in social-emotional reciprocity, deficits in non-verbal communication, deficits in developing, maintaining and understanding relationships
B. Restricted, repetitive patterns of behaviour, interests or activities, as manifested by at least 2 of the following: stereotyped or repetitive motor movements, use of objects or speech, insistence on sameness, inflexible adherence to routines, or ritualized patterns of verbal or non-verbal behaviour, highly restricted, fixated interests that are abnormal in intensity or focus; hyper or hypo-reactivity to sensory input or unusual interest in sensory aspects of the environment
C. Symptoms present in early developmental period
D. Clinically significant impairment in social, occupational or other areas of function
E. Not better explained by ID or GDD-- social communication is below expected general developmental level.

29

ASD Specifiers DSM V

with/without accompanying intellectual impairment
with/without accompanying language impairment
associated with known medical or genetic condition or environmental factor
associated with another neurodevelopment, mental or behavioural disorder
with catatonia