NR 602 WEEK 4 MIDTERM STUDY GUIDE WITH ANSWERS | NEWEST VERSION GRADED A

NR 602 WEEK 4 MIDTERM STUDY GUIDE WITH ANSWERS NR 602 WEEK 4 MIDTERM STUDY GUIDE WITH ANSWERS Toddler: 12-24 months Preschoolers: 2-5 years old WHO growth charts should be used to measure weight and length for children less than 24 months CDC weight and length charts used for children older than 24 months Average 24 month weighs 26 lbs, length 33.5 in and HC 18.5 in Most have no palpable fontanelle by 12 months Ant fontanelle closes by 18-19 months 3-6 yrs weight gain expectation is 4.5-6.5 lbs/year 3-6 yrs height gain expectation is 2.5-3.5 inches/yr 4 yrs length at birth has doubled 4-5 years old legs grow faster than rest of the body Use of dominant hand may appear as early as 8-12 months generally emerges 2-4 years old; handedness established at 5yrs May develop bowel and bladder control by age 3, but many will not. Boys usually take longer than girls to maintain bedtime bladder control. Articulation: -24 months- 25% is understood by a stranger -24m-36m- 66% is understood by a stranger -3 years old- 90% should be understood by a stranger 3 and 4-year-old have a normal hesitance or show stuttering, considered abnormal if beyond 5 years of age Speech problems often can be from lack of stimulation, hearing problems, ear infections, developmental delay. Early detection important. Lexicon: girls typically say their first word between 8-11 months; boys by 14 months 2 year olds: have more than 200 words in their vocabulary 3 years old: 900 words in vocabulary 3-4 yrs old: able to follow simple commands, talks incessantly 4-5 year olds: add at least 50 new words a month; words in vocabulary (including names, coins, colors, knows days of the week) 5 year olds: should be able to define certain words with other words (cup: something you drink with) Syntax: 8 months: develop receptive language- they understand what a word means before they are able to use it themselves 12-28 months: use holophrases (single words) to express whole ideas 18 months: use telegraphic speech (get milk, go bye-bye) 2 years old: short sentences 3 years old: add plurals, 3-4 word sentences 4 years old: past tense 5 years old: syntax is close to adult style, 5-6 word sentences Peer relationships: Toddler: parallel play Preschoolers: more interactive and social, imaginary play Body image: Masturbation starts around 3-4 years old Theories: Erikson Industry team sports/cooperation Master social studies, math and reading sense of competence and accomplishment Development of a of “superego” or conscious develops during preschool age Inferiority children must learn that they will not be able to master every skill they attempt Criticism detrimental at this age Piaget Concrete operations More tolerant and perceptive of other’s viewpoint Children are able to use thought processes to experience events and actions Judgments made based on reason (conceptual) Ages 2-4-Starting to realize world outside their own, realizing they can make things happen (shift from egocentric. Belief in “magical” power of words. Ages 4-7- Preoperational intuitive thought- starting to understand time concept but limited. Example may understand “after lunch” instead of in 2 hours. Kohlberg (moral development) Judge an act based on consequences of reward and punishment They know the rules and behaviors expected of this, but do not understand the reasons behind them Can accept the concept of treating others as they would want to be treated. Judge an act based on intention not just consequences Piaget: Preoperational thinking (2-4yrs) - problem solving based on what they see directly egocentrism - only about them Centration - Focus only on 1 thing at a time Animism - things around them are alive Magical thinking - thoughts are all powerful - their thoughts can cause things to happen Developmental Assessment: BP starts at 3 years old or if at high risk Hearing and Vision at 4-5 years old Dentist: first tooth eruption or before 12 months; eruption of permanent teeth start at 5 yrs 3 years: Draw circle, cross and vertical/horizontal lines 4-5 years: Trace cross & copy a square, ties shoelaces 5-6 years: Draw a person, copies a diamond and triangle, can print name 2-4 yrs: Animism and magical thinking Magical thinking continues into 4-7 years Screening Tools: Ages and stages Questionnaire: helps with evaluating fine and gross motor development M-CHAT: evaluates for autism (used for children 16-30 months) Early language milestone (ELM): brief screening for speech intelligibility (3-4 years old) Preschool decision: parents should select a preschool with a play based learning curriculum Immediate referral is required for children who stop eating, demonstrate cruelty to animals or other people, are self- harmful, start fires, or talk of harming themselves, their peers or others Children with scores below 85 on intelligence scales predictably have more difficulty in school Language development is the best indicator of cognitive development, language delays may indicate serious issues that require developmental and educational intervention Vision screening 5y, 6y, 8y, 10y, 12y. Referral with acuity less than 20/40 (aap guidelines) Hearing screening 5y, 6y, 8y, 10y. (aap guidelines) Immunization: Hep Bx3: NB, 1-2 mths, 6mths Hib x4: 1-2 mths, 4 mths, 6 mths, 12-15 mths Rotavirus x3: 1-2 mths, 4 mths, 6 mths PCV x4: 1-2 mths, 4 mths, 6 mths, 12-15 mths DTaP x5: 1-2 mths, 4 mths, 6 mths, 15-18 mths, 4yr Polio x4: 1-2 mths, 4 mths, 6 mths, 4-6y MMR x2: 12-15mths, 4yr Varicella x2: 12-15mths, 4yr Older child Tdap x 1: 11-14yr Meningitis x2: 11yr, 17yr HPV x2 (6mths apart): 11-13yrs Hep A x2 (6 mths apart): between 12-23mths, recommended before middle school if not had earlier Safety Helmets, seat belts, still keep cleaning supplies out of reach/locked up. Gross Motor Development 3 years •Rides a tricycle •Walks on tiptoes •Stands on 1 foot for a few seconds •Broad Jump 4 years •Catches a ball •Hops & skips on one foot •Walks up and down stairs using alternate feet 5 years •Jumps rope, begins to skate and swim •Walks backwards heel to toe •Skips and hops (alternate feet) Sleep 12 hours at night, no naps but quiet time Nightmares - During REM sleep, fully awakes, able to be reassured, occurs at end of the night Night terrors - No during REM, not aware of others, partial arousal, no memory of dream, earlier in the night Child Aggression: Not necessarily the behavior itself that is the issue but the frequency, severity, timing. Frustration is the biggest reason they act out. Can also happen if parent is depressed, child is neglected, etc. School Age Children Age 5-12 years Early Childhood (5 to 7 years) Middle (8 to 10 yrs) Late (11 to 12 yrs) Small amount of breast tissue in males normal during puberty-gynecomastia Encourage sports activities Growth and Development Building self-esteem- praise important Check immunizations at sick visits- no immunizations if fever within past 24 hours Get them to talk to you during the visit No shots until age 11 after 4 year old ones Age 7 cholesterol (guidelines between 7 and 11) If BMI 95%, obesity panel- A1c Vision and hearing often done in school Important to ask about friends and peer groups Physical development: strength coordination increase, growth spurts occur, cerebral cortex/frontal lobe develop Motor skills: run, jump, skip, hop, overhand motion, balance coordination improves Fine motor skills: improve dexterity, use scissors, writing tools, hand-eye coordination improves Psychosocial development: Erikson. Industry vs Inferiority. Industry: Development of formal skills, extrinsic rewards important like grades, cooperation, competition and coping leads to sense of accomplishment. Inferiority: ▪Danger during this period, especially for those with physical and mental limitations * No child is able to do everything well, and children must learn that they will not be able to master every skill they attempt Conceptual vs perceptual thinking: based on reason (conceptual) rather than what you see (perceptual). 95210 plan might be important, encourage reading. Communication and language development: Improved communication skills, 8-9 year olds can understand jokes, meanings, stuttering should resolve by school age. 10-12 year olds understand metaphors, ambiguities of language, speech and language disorders among the most developmental delays. Language development: 6-7 years: 2000 words, trouble with s, l, and r 7-8 years: should not have reversal of letters 8-9 years: can recognize and correct spelling and grammar 12 years: 4000 words, can correct syntax and semantics Social/Emotional: Social cognition results from parent child relationship Gain impulse control/manage emotions, learning to interpret social cues, parent should be parent, no friend Through peer relationships children learn that the world is somewhat different from their own. They learn how to deal with dominance and hostility, to relate to people in leadership and authority positions, and explore different ideas. -”Best Friends”: Important to the foundation of relationships in adulthood. They share secrets, private jokes, adventures, and come to each other’s aid in times of trouble. They also fight, break-up, and re-unite. -Clubs and Peer Groups: Rules and selection of joining. -Bullying: “Any recurring activity that intends to cause harm, distress, or control towards another in which there is a perceived imbalance of power between the aggressor and the victim” (Lamb, Pepler, and Craig, 2009). -Bullies are usually defiant towards adults, antisocial, and likely to break school rules. Victims often experience social distress such as worry, sadness, anxiety, depression, and nightmares. Gender: Early school-age – few gender differences; Older school-age – tend to associate with own gender Rules: Part of the enjoyment of the game is knowing the rules “Chants and Taunts”: Sense of power and pleasure with saying them. “Last one is the rotten egg!” “Step on a crack, you’ll break your mothers back!” Collections: Early School Age- odd assortment of things, messy Later School Age- more organized and selective Games: Adhering to the rules is a must! Reading: Newly acquired skill becomes increasingly satisfying. Never tire of stories (hearing or reading). Also enjoy creative and physical activities such as sewing, cooking, painting, swimming, soccer, or dance. Common fears: fear of the dark, self-consciousness, excessive worrying about past behavior. Symptoms of stress / fear: recurring stomach pains or headache, aggressive or stubborn behavior, regression to earlier behaviors such as thumb sucking, reluctance to participate, sleep problems, changes in eating, bed-wetting. Must provide reassurance to the child that they are safe, have honest and open communication, encourage them to express their feelings, and provide time for structured play. Just a noted about self-consciousness: school-age children generally have an accurate and positive self-perception. The more confidence that can be built during this period the better – it will carry forward into the future. May respond to pain with muscular rigidity: Anticipatory guidance: discuss sources of iron, calcium, vitamin c, vitamin d. Discuss prevention of obesity, exercise. Physical characteristics: ▪Slowed growth ▪2 inches per year ▪4-6 pounds per year Average 6 year old: 45 inches and 46 pounds Average 12 year old: 59 inches and 88 pounds ▪Pre-pubescence ▪From middle-childhood until 13 yrs old ▪Secondary characteristics Body image & Self concept Dental: ▪Permanent adult teeth development, Lose 4 teeth per year, Begin with eruption of 6 year molars ▪Attention to dental hygiene and caries is important The first physiological signs appear around 9 years of age (especially in girls) and are usually evident clearly visible in 11 to 12 year olds. Generally puberty begins at age 10 in girls and 12 in boys, but it can be normal for either sex after the age of 8 years. Nutrition: avoid empty calories, develop a new taste. Caloric needs for 6-12 year olds: boys 16-17 kcal/cm. girls: 13-14 kcal/cm. Sleep: start good habits such as no tablets in bed. ▪Highly individualized, Rarely takes naps Average 5 year old: 11 hours per night Average 12 year old: 9 hours per night ▪Bedtime resistance peaks from 8-11 years Safety: The most common cause of severe injury and death in the school-age child is motor vehicle accidents (MVA), either as a pedestrian or passenger. *The rear seat is the safest place for children less than 14 with booster seats until 80 pounds of 8 years of age. WEEK 2 : chapter 8 Adolescent 13 years is the age of consent in MD The common question on the minds of most adolescents: Am I normal? Adolescence: refers to the psychosocial and emotional transition from childhood to adulthood Physiologic Changes of the Adolescent • Increased size and strength of heart • Lungs increase in size • Continued brain development • Muscle & Fat changes • RR dec, HR dec, BP increases Tanner stages: Tanner 1: no growth of pubic hair Tanner 2: initial, scarcely pigmented straight hair Tanner 3: sparse, dark visibly pigmented curly hair Tanner 4: hair coarse and curly, abundant, but less than adult Tanner 5: lateral spreading; type and triangle spread of adult hair to medial surface of thighs Tanner 6: further extension laterally, upward, or dispersed (occurs in only 10% of women) Female stages: females enter puberty earlier than males do, following pattern: -ovaries increase in size, no visible changes occur -breast budding between 9-10 years old, and initial breast development at 12, breast buds approximately 6 months before the appearance of pubic hair, the timing of the onset of breast development in females has no relationship to breast size at the completion of puberty -95% of females reach peak height velocity (PHV) between the ages of 10 and 14 years old, and most girls experience PHV about 6-12 months before menarche, generally by 11-12 years -appearance of pubic hair - about 11.5 years old -first menstrual period- about 12.5 years old, it may be 18-24 months after menarche before females establish regular ovulatory cycles, first menstrual cycle typically consistent with tanner stage 3 Initial breast development usually begins as a unilateral disk-like subareolar swelling, and many are concerned with breast tumors -girls often have asymmetric breasts and need assurance that breasts become more or less the same size within a few years after the onset of breast budding They enter puberty with approximately 80% lean body weight and 20% body fat. By the time puberty ends, lean body mass drops to about 75% Male stages: the initial sign of male puberty is testicular enlargement on average at 11 years: -growth of the testes occurs approximately 6 months before the development of pubic hair in most males, once puberty begins, the left testis hangs lower than the right -pubic hair development happens similar to a girls (tanner stage) -first release of spermatozoa: occurs between 13.5-14.5 years old -growth spurt: occurs between 12-16, males can continue to grow, although minimally well beyond their teenage years -change in the male voice coincides with PHV (peak height velocity) Concerns for delayed puberty when there is no enlargement of the testes by age 13.5-14 years of age The taller the boy the more delayed onset of puberty In contrast to females, males increase in muscle mass and decrease fat Up to 65% of males experience gynecomastia especially within a year of achieving PHV, generally lasts 12-18 months and resolves on its own Acne starts in early puberty, and by mid puberty many males have moderate to severe acne Adolescents have formal operational thinking Egocentrism of adolescents: four major types of egocentrism: -imaginary audience: Everyone is thinking about them -personal fable: they are special -overthinking: they make things more complicated than they are -apparent hypocrisy: rules apply differently to them than others Principles and approaches to assessment: -teens must be evaluated independently from parents -should be reassured the information they share will be confidential (there are limits, providers are required to report information that puts the child or others in danger: physical or sexual abuse, some states require teen sexual activity, even if consensual, if an age difference of 3 or more years exist between the couple) Physical Assessment: - should have height, weight, BMI, and BP measured at each health maintenance visit -tanner stage should be recorded at each visit to evaluate progression -testicular growth can be directly assessed by palpation of the testes in the scrotum and comparison of their size with a standardized orchidometer -varicocele or enlarged veins palpable in the scrotum may develop at sexual maturity and are not cause for alarm unless a discrepancy in testicular size is noted -note gynecomastia -check for scoliosis -thyroid gland should be assessed -question attitudes regarding physical growth and development Cognitive development: -should include questions about school attendance, school performance, and educational/career goals Phases of adolescence: Early adolescence (11-14 years old): most difficult period -Physical development: tanner stage 3 or 4, some can be at 2 until 14 -Cognitive development: daydream frequently, set idealistic goals that change frequently, some experience a drop in academic performance in junior high school, which is related to motivation rather than ability -Social and emotional development: anti-adult, like their friends more -Health supervision: immunizations for HPV, diphtheria and tetanus toxoids and acellular pertussis vaccine (DTaP), influenza, Hep A, and meningococcal meningitis is recommended (before middle school and before college), serum lipoprotein analysis should be done if not done earlier in childhood -Anticipatory Guidance: increase iron and calcium intake is needed when menstruation begins, and during periods of rapid growth Red flag if boys do not increase testicle size by age 13.5-14 Middle Adolescence (15-17 years old): stand out for their unique appearance -Physical development: physical development is nearing completion, less concern about body changes more interest in being physically attractive -Cognitive development: school and extracurricular activities are often the focus -Social and emotional development: tend to be more non-adult than anti-adult, a characteristic of early adolescents, sexual drive emerges and middle adolescents begin to explore their ability to attract a partner -Health supervision: influenza, developmental surveillance, and assessment of social and academic progress, quality of interpersonal relationships, school performance, and emotional wellness , screening for STIs if sexually active, PAP smears no longer recommended until after age 21 regardless of sexual status -Anticipatory guidance: focuses on teens expanding physical, cognitive, and socioemotional capabilities, consolidating self-concept and identifying areas of continued growth and development Late Adolescence (18 to 21 years old): autonomy -Physical development: typically complete -Cognitive development: adult level of reasoning -Social and emotional development: usually relate to the family as adults -Health supervision: influenza, screening STIs, PAP smear begins at 21, fasting lipoprotein analysis is recommended once during late adolescence, transition in providing medical records and referring the adolescent to an adult health care provider -Anticipatory guidance: centers on transition from being a teenager to taking on the responsibility and role of an adult Risk behavior assessment: -HEEADSS (Home, Education and employment, Eating, Activities, Drugs, Sexulaity, Suicide/Depression, and Safety) -Tobacco use: direct questioning is the best way to assess smoking patterns -Self-Injurious Behaviors: history should include focused questions about present and past experiences with self-injury, description and mental and emotional responses; the most common locations include the arms, legs, and front of the torso -Social media use: have open discussions regarding social media use, approach teens non-judgmentally to bring up usage concerns Sexual Activity average age of initiation is 17 yrs Nutritional Needs Increased! Female: 9-13 years - sedentary- cal/day, Moderately active - cal/day, Active - cal/day 14-18 years - sedentary - 1800 cal/day, Moderately active - 2000 cal/day, Active - 2400 cal/day Male: 9-13 years - sedentary - cal/day, Moderately active - cal/day, Active - cal/day 14-18 years - sedentary - cal/day, Mod active - cal/day, Active cal/day Adolescent interviewing Respect and understand the psychological stage of the adolescent Empower them to take ownership of their health and well being Establish trust Week 5: Pediatric Orthopedics 3/1/2018 Condition Manifestation Prevalent age H & P Dx test Treatment Teaching Nursemaid Elbow Immediate pain, whiny, not moving arm 1-5yrs Pain on palpation, no increase in pain over the supracondylar region, no swelling or deformity, Classic sign is subluxation Reduction maneuver (Only attempt the reduction after checking NV status and supracondylar region) Distal radius buckle fx Hx of outstretched hand fall Pain at distal radius, with grip and flexion, swelling. No initial deformity x-ray Splint, can be for 4-14 day before able to see ortho, short arm cast 4-6wks Return to play with full strength and ROM Non- accidental traumas Assess for abuse. Red flags: inconsistent hx, tx delayed, multiple fx xray ER will do xray of skull and skeletal survey Avoid judgement, team approach. Tactfully send to ED, work up will be done there 5-10% increased r/o death if unrecognized and sent home Growing pains Leg pain (usu. bilateral), usu. at night more common in boys 2-5yrs and tweens, during growth spurt rare to have fever, wt loss and malaise No xray, pain usu. in thighs & lower legs reassure, mild analgesic (Ibuprofen cos is an anti inflammatory), gentle massage. Clavicle Fx Bony point tenderness over clavicle, skin tenting, necrosis possible visible deformity, increased pain, point tenderness at clavicle. Palpate Acromioclavicular joint & Sternoclavicular joint. Skin tenting can progress to pressure necrosis- open fracture! xray Refer to ED immediately, risk of frozen shoulder and necrosis of the socket. Immobilize 4-6 weeks in a sling . PE: bony point tenderness over clavicle, must palpate AC and SC. Must check for abrasions or lacerations- open fx! Want to prevent frozen shoulder and necrosis of joint. Narcotic pain often required, consult ortho if open, significant angulation, lateral third fracture, or significant shortening. Must assess need for immobilization vs immobilization and reduction. No contact sports 8 weeks Gradual return to play, must have full ROM and strength to return to play Osgood- Schlatter disease Osteochondritis of the tibial tuberosity. Increasing knee pain, Overuse injury or repetitive stress of the quadriceps muscle Common in girls & boys ages 10-15 years participating in competitive sports but in boys Soft tissue edema over proximal tibial tuberosity Tenderness to palpation of proximal tibial tuberosity. Sharp bump over the shin called tibial tubercle. Pain with knee extension against resistance Absence of effusion, pain of anterior knee NSAIDS, ice, restrict activity, PT, May not need to refer but refer to ortho if does not improve. Pain subsides with rest and activity modification, may last for awhile, restrict activities Sever’s disease results from inflammation of the growth plate in the heel. higher risk in pronated foot, flat or high arches, short leg syndrome & overwt . AKA calcaneal apophysitis, most common etiology of heel pain in growing children, pain in Sever disease is believed to be repetitive trauma to the weaker structure of the apophysitis induced by pull of the Achilles on its insertion growing children, also during growth spurt of adolescent children painful heel. Difficulty walking, discomfort when heel is squeezed, stiffness upon awakening, toe-walking, limping. xray may not be necessary unless condition persists after tx NSAIDS, ice baths, heel pads, heel stretching, calf strengthening. May refer to PT and OT if no improvement Symptoms worse during or after activity, better with rest, progression to activity as tolerated Legg calves - perthes Avascular necrosis of the femoral head. Insidious onset, painful limp, hip pain then groin, thigh and knee pain, hip motion. Can be bilateral, self-limiting 3-12 yrs, in boys **age is a big factor in determining outcomes (early identification is key) Afebrile, Trendelenburg and assess gait, leg length discrepancy, antalgic (avoid pain) gait, thigh atrophy, decreased abduction and internal rotation of hip. xray showing There is a flattening and fragmentation of the femoral head. Bone scan can ID avascular necrosis Refer, self limiting, limp can last 2-4yrs, stretching, bedrest, casting, NSAIDS, Pelvic/femoral osteotomy to contain femoral head. crutches & bracing Goal: to prevent hip from dislocating Slipped capital femoral epiphysis fx of the growth plate which leads to the slipping of the femoral epiphysis off the femoral neck Overwt and association with hypo- thyroidism and endocrine disorders; seen in preteens and teens usually complains of thigh or knee pain and holds the extremity externally rotated. Resists internal rotation. knee pain is hip pain unless proven otherwise, can have groin pain radiating to the knee, worsening pain xray +ve Pinning of the joint, child should be admitted to the hospital immediately and placed on bed rest. Refer immediately to ortho surgeon. Place on crutches or wheelchair, non-weight bearing needs to be emphasized. Transient synovitis acute onset of atraumatic groin or hip/thigh pain that is unilateral and a limp or unwillingness to bear weight 2-8 yrs acute onset, Sudden pain, r/o bacterial infection of joint or bone. US IDs effusion seen in TS and septic arthritis. Xray can show medial joint space widening & can exclude SCFE & Fx. WBC, ESR, CRP are norm or slightly elevated. Xray is norm unless effusion is present. Bone scan can differentiate TS and SA from osteomyelitis association of preceding viral illness 2wks-1mth prior with n/v, diarrhea and cold symptoms Plain radiographs exclude SCFE and fracture, x-ray may show medial joint space widening, lab work would be WBC, ESR, CRP, and if normal likelys TS, if elevated can still be that so MRI or aspiration of the fluid present on hip. Bone scan can differentiate between septic arthritis or TS from osteomyelitis Oesteomylitis Infection of the bone. Mostly long bone. May have hx of trauma. Most common organism is S. aureus Fever and ill appearing, limp or refusal to stand, point tenderness. Acute: Fever that may be abrupt. Irritability or lethargy in young children. Pain, swelling, warmth and redness at the area of the infection Chronic: Chronic fatigue, pain, swelling, warmth, drainage. May have fever Elevated ESR, CRP and WBC. Needle aspiration of fluid. Bone scan. Need BCx too IV antibx long term 4-6mths Septic Arthritis Microbial agent in the joint space. Ortho emergency, delay will lead to irreversible damage Pseudoparalysis due to pain, unable to perform ROM, severe pain and acute inflammation US can ID effusion, If the US is positive for an effusion it should be followed up by lab work (CBC with diff, CRP, ESR). elevated WBC, ESR CRP may indicate SA or osteomyelitis, confirm with MRI or an aspiration of fluid Lyme’s arthritis Arthritis is Initial sign of lyme’s disease in children. targets large joints symptoms mimic SA Scoliosis spinal curvature occurring in normal healthy patients more freq in females Adam’s forward bending test. perform neuro exam. assess for hairy patches, dimple, nevi, muscle weakness, neuro abnormalities Scoliometer MRI, CT scan Exercise, brace 25-40 degrees for 20-22 hrs/day, Spinal fusion for 45-50 degrees Ortho emergencies and urgencies: septic arthritis, neurovascular compromise, compartment syndrome, unstable slipped capital femoral Bowed legs- blount's disease, should be corrected by 4 In-toeing -18 mths start to straighten out usu done by 3 or 4y Out-toeing Toe-walking – may be seen with autism, may be out of habit Concern with kids with rickets, will see bowed legs at 4 – vit D levels, calcium Where is the source of pain and what is the condition? Hip - SCIFE Thigh - Femur condition Knee - Leg - tibia Ankle joint - MG Foot - Tarsals & metatarsals Age and likelihood of disorder Newborns and infants ( 1 yr) Toddlers (1-3 yr) Older children (4-10 yr) Pre-teens and teens ( 10 yrs) Obtaining hx What is the specific concern? • Pain/tenderness, limp, trauma/injury, or overuse, swelling, ability to bear weight, ROM…where? UE, LE, groin, foot/ankle, back… Who is concerned? When does it manifest? Daytime, nighttime, activity, jumping, walking up & down stairs? Characteristics? Duration? Improving or worsening? Any witnessed trauma Swelling without trauma - is more worrisome Swelling with trauma Warmth or erythema Swelling and erythema- thinking of cellulitis Systemic symptoms- fever, rash, foreign body, mass (could be sarcoma with mass) Ask for ROM Unable to walk With shoulder breaks, would check pain control, blood flow (circulation checks), compartment syndrome Assess for fluid with bulge sign and ballottement sign. Thomas test is for hip flexion if contracture is suspected 24 hour creatine-creatinine ratio to test for muscle disease Urine Uric acid –24 hr specimen for gout Urine Tests – creatine-creatinine ratio for test presence of muscle disease; Urine deoxypyridinolie – assess bone resorption process A Bone scan can differentiate septic arthritis or TS from osteomyelitis. In more chronic case it can be used to identify avascular necrosis or Legg-Calve-Perthes disease earlier in the course than can a plain radiograph. Bone scan can also help diagnose tumors and myelodysplastic disease Sprains Overstretching or tear Ligament injury (Excessive stretching of a ligament) Twisting motion Grade I—mild bleeding and inflammation Grade II—severe stretching and some tearing and inflammation and hematoma Grade III—complete tearing of ligament Grade IV—bony attachment of ligament broken away Treatment of sprains: first-degree: rest, ice for 24 to 48 hr, compression bandage, and elevation second-degree: immobilization, partial weight bearing as tear heals third-degree: immobilization for 4 to 6 weeks, possible surgery Nursing care for sprains R- rest I- ice C- compression E- elevation Strain Microscopic tear in the muscle May cause bleeding “Pulled muscle” Inappropriate lifting or sudden acceleration-deceleration Fractures Random Case study in class Mono- prolonged fever Neuromuscular conditions Cerebral Palsy Cerebral Palsy is a brain disease causing paralysis Can be caused prenatally: by infection, hypoxia, radiation, preexisting brain abnormalities OR Can be caused postnatally: by infection, hypoxia, head trauma, meningitis, apgar scores 3 at 5mins, extreme preterm Rarely caused by genetic complications It is a non-progressive disease Types of CP 1. Spastic- hypertonia, most common type, from lesion in upper motor neurons, adductor muscles constantly flexed, scissors gait, calves are flexed causing achilles tendon to pull up and leads to toe walking 2. Dykinetic- damage to the basal ganglia which inhibit and prevent movement, damage will lead to involuntary movements, nonspastic a. Athetoid- facial grimace, trouble swallowing, drooling, speech impairment, involuntary movement b. Dystonic Ataxic (without order)- caused by damage to the cerebellum which controls coordination and precise movements, may seem clumsy, poor balance and muscle coordination, unsteady wide gait, nonspastic Mixed type 6 mth old child who reaches for toy with right hand f/u assessment for CP Will have increased reflexes due to spacisity. Can get CP from having group B strep as young baby. Diagnosis plan for CP Developmental screen Neurological examination EEG Neuroimaging Cytogenic & metabolic studies to r/o other causes Problems associated with CP Delayed and decreased gross motor development, decreased coordination Problems sucking, feeding, swallowing Mental retardation seen in 18-50% Learning disabilities Seizures Sensory deficits - speech, vision and hearing Signs of possible CP Persistent primitive reflexes Arching back Poor head control at 3mths Fisting after 3 mths No smiling at 3 mths Unable to sit without support at 8 mths Rigidity or floppiness Excessive irritability Feeding difficulty - tongue thrusting past 1yr, freq gagging or choking while feeding Goals for CP Establish mobility, communication and self help skills Correct associated defects as effectively as possible Gain optimal appearance and integration of motor fns Provide adapted educational opportunities Promote socialization with other affected and non affected individuals Treatment Not curable but treated to improve quality of life Interdisciplinary team. Referral to neurologist, rehabilitation - PT, ST (infants and toddlers), OT Physical Therapist help to improve strength and walking ability, stretching to reduce contractures Medications • Muscle relaxants - diazepam and baclofen pump • botulism can be given to reduce hypertonicity • Antispasmodics- Botox • Analgesia • Antiepileptics (with seizures) Braces and supportive devices Surgery to loosen muscles, cut nerves to reduce movements or spasms and straighten bones Dental care Well child care School • hearing aids and glasses • OT to help with writing or keyboarding. May use bigger grip pencils, crayons, utensils Social support • stress management and community resources Nutrition- esp. high fiber diet to prevent constipation Safety With an artificial urinary sphincter it may be possible to potty train CP and IQ Varies widely 70% with normal IQ Rigid, atonic, and quadriparetic CP patients have the highest incidence of profound impairment (mentally) Muscular dystrophies (MD) Is a degenerative, genetic disease. progressive weakness and wasting of skeletal muscles; increasing disability and deformity. Is an X-linked disease.CPK and AST are high in first two years of life Gowers signs to stand up, lordosis common Duchenne Muscular Dystrophy Most common and most severe MD Family is a big factor, seen in 60% of new cases Case Study: 15 yr old male, Dx with DMD at age 5, Wheelchair bound since age 9, Bipap at night, 5kg wt loss in 3 mths, now with complaints of difficulty swallowing, • What diagnostic work-up is indicated? Swallow study (condition may cause aspiration), EMG (electromyography) to check muscles • What is the prognosis for this condition (life span mid 20s) • What tx/therapies are needed (thicken feeds, slow softer foods, feeding tube, speech, PT) • What consult/referrals should be placed? Characteristics Early in life appropriate development or slight delay Onset 3-7yrs Notice hypertrophic calf muscles but weak Death from respiratory or cardiac failure Dx eval Prenatal testing if have family hx Clinical presentation Blood test: PCR for dystrophin gene mutation Confirm with EMG, muscle biopsy, and serum enzyme measurement Serum CK, AST and ALT are elevated. CK will be 50 times the normal (37-430U/L) Elevated CK and AST within first 2 yrs of age shows an inflammatory response can be an indication of DMD before s/s of weakness are expressed Manifestation Waddling gait, frequent falls, Gower sign Lordosis (once they get to wheelchair bound) Enlarged muscles, especially in the thighs and upper arms Profound muscular atrophy in later stages Mental deficiency is common Management Goal to keep unaffected muscles functional for as long as possible keep as active as possible Steroid use may delay wheelchair dependence (prednisone keeps them mobile longer) ROM, bracing, surgery to release contractures, performance of activities of daily living Bipap to help with respiratory health Guillian-Barre syndrome (GBS) Also known as infectious polyneuritis. Acute demyelinating polyneuropathy (damages the peripheral nervous system) with progressive paralysis. Immune-mediated disease. Often occurs 10 days after a viral infection. Has associated with some vaccine administration. HIgher incidence in children 4-10yrs, 16-17, young adulthood, in males. Inflammation and edema in the spinal column, progression from the cranial nerves to impaired nerve conduction then to partial and complete paralysis. Case Study: 17 year old male, Hx influenza 2 wks ago, Ataxia, HA, blurred vision, Limping unable to stand on 1 foot, Denies fever, Labs norm CBC and electrolytes, What other studies would you do Laboratory Imaging: MRI or CT scan Prognosis The younger children have better outcomes, most patients with complete recovery. Muscle function regained in 2 days to 2 weeks after onset of symptoms. Prolonged period of recovery. May be placed on ventilator. Deaths are often due to respiratory failure. Manifestation Initially, muscle tenderness, paresthesia (burning or prickling sensation), muscle weakness. By the 3rd week, 90% of patients are at their weakest Paralysis rapidly ascends from the lower extremities; may involve the trunk, arms, and face Flaccid paralysis; loss of reflexes Intercostal and phrenic nerve involvement (need ventilator) Frequently have urinary incontinence or retention and constipation Dx eval Progressive paralysis and/or EMG Normal lab values but elevated protein in CSF fluid Bilateral, symmetric paralysis Management Treatment symptoms Medications • Steroids (controversial) • IV immunoglobulin (IVIG), prefered to plasma exchange in the peds population cos plasma exchange is invasive and time consuming • Heparin, stool softener, analgesics Plasmapheresis Respiratory support Emotional support for the child and family Supportive care with a multimember health care team Assess for early signs of respiratory distress or difficulty swallowing, may need ICU care Focus on prevention of complications Skin, nutrition, and muscular support measures Myasthenia Gravis (MG) Is rare in childhood, autoimmune, autosomal recessive mutation disease; more common in oriental population. Presents with varying degrees of weakness and fatigue. Case study (recommended reading): 2 y.o. girl presents with refusal to walk, symptoms started 3 wks ago with fever of 104 and difficulty bearing weight on both lower extremities. xray unremarkable at the time but was positive for AOM which was tx’d with amoxicillin. 1 wk later limp worsened, tx at a community clinic was NSAIDs and heating pads. Further progression brings her to the hospital; no hx of trauma or resp. s/s but 3 mths prior had bloody diarrhea +ve for E. coli and Shigella. Immunizations UTD. PE: Afebrile, HR 100, RR 24 BP 84/60. full ROM bil. at hips and knees, no deep tendon reflexes in LE at both knees and ankles, limited dorsoflexion of the R foot, no swelling, erythema at any joints. other exam was normal. Labs: CBC, CMP, CK, CRP, antinuclear antibodies WNL but ESR slightly elevated at 25mm/hr. LE xray and bone scan are -ve What further test would you do? MRI and CSF Neonatal MG: Born of mother with MG, Transplacental transfer of AchR antibodies, Self limiting Juvenile MG: Born of a non-myasthenia gravis, can happen at anytime from birth to puberty and tends to be permanent Manifestation Ptosis and ocular symptoms Generalized muscle weakness Fatigue Dysphonia (difficulty speaking) Dysphagia Proximal limb weakness Transient Neonatal myasthenia Dx eval Symptoms- Ptosis and eye issues are number 1 symptom Family history Edrophonium (Tensilon) test- is a rapid-acting anticholinesterase drug of short duration that improves symptoms of myasthenia gravis by inhibiting the breakdown of ACh and increasing its concentration in the neuromuscular junction Electrophysiology DNA analysis Muscle biopsy Serology: AChR antibodies Management Multidisciplinary approach Acetylcholinesterase Inhibitors (Pyridostigmine) Thymectomy Immunosuppressive therapies with steroid-sparing immunosuppressants IVIG for short term improvement Nursing Considerations: Vision, Safety, Speech, Swallowing, Respiratory Week 4 (3/22) Mental Health Psychiatric Disorders in Children – Mental Health – Emotional Well-being, “balance”, appropriate level of functioning in all aspects of life Mental Illness – Some level of dysfunction, “imbalance”, causing functional impairment. An impairment in thinking, mood, or behavior that affects functional ability. • A syndrome characterized by clinically significant disturbance in an individual’s cognition, emotion regulation, or behavior that reflects a dysfunction in the psychological, biological, or developmental processes underlying mental functioning. • Usually associated with significant distress or disability in social, occupational, or other important activities. Neuron• Basic unit of the brain • Transmission of electrical impulses to other cells • Communication occurs at the synapse • Neurotransmitters released from one neuron are received at the other, after crossing the synaptic cleft Neuroplasticity: The brains ability to change in response to experiences related to the amount of effort such change requires. Children have great neuroplasticity. As person ages the brain has less and less ability to change in response to experiences and it takes more and more energy for it to do so. Stress Diathesis Model: How physiological disorders occur • Diathesis – predisposing factors, directly impact vulnerability to psychologic d/o (or how stress is handled) o Genes o Abnormalities of brain structures o Neurotransmitters • Stressors – external factors, triggers o Noxious physical stressors o Trauma, abuse, neglect o Relationships – loss, turbulence o Culture related stressors Assessment of potential psychiatric disorder • Major Rule-outs: o Organic o Developmental o Environmental o Substance, medications, or toxin-induced origin • Consider multi-factorial causes • Consider Developmental stage o Behavior congruent o Hormonal changes • Diagnostic evaluation: o CBC, CMP, thyroid panel, LFT’s, blood glucose, lipid profile, tox screen (if substance abuse is suspected) o EKG o EEG – seizure activity ? • DSM-5 Cross-cutting symptoms – symptoms can appear across disorders o Check list of 25 items to assist in narrowing potential diagnosis (12 psychiatric domains) o Measures symptoms in past 2 weeks o Initial diagnostic guidance or presentation over time General Risk Factors – weighted heavily on heredity - parental mental d/o, absence/death of either parent, abuse/neglect, insecure attachment, parental unemployment or financial problems, teenage mother, low parental involvement, poor self-esteem, poor physical health, peer rejection, poor attachment to school/school failure, socio-economic disadvantage, neighborhood violence & crime General Protective Factors – strengthen mental health – good family/social support, strong family norms, economic security, good coping skills, social competence, positive self-esteem, above average intelligence, moral beliefs/values, good physical health, positive school climate/belonging, connectedness to community, support from adults other than parents Mental Status Evaluation • Physical Appearance o Grooming, facial expressions, mannerisms • Parent-child interaction o Waiting area, exam room • Separation and Reunion o Lack of affect or severe distress • Orientation – timing, place, person • Speech and Language o Age appropriate; hearing loss • Mood o Visible expression/behavior, verbal • Affect o Range of emotion, lability, congruence with mood (reported mood doesn’t jive with what is being seen in office or stated as seen at home) • Thought Process and Content o Age appropriate; suicidality, psychoses • Social Relatedness o General interactions; self-esteem, family/peer relationships • Motor Behavior o Coordination, activity level, involuntary movements • Cognition o Intellectual function, problem solving • Memory o 3 objects after 5 min’s; 5 digits forward, 3 backward • Judgement and insight o Age appropriate understanding Common Pediatric Psych Diagnoses • Anxiety D/O – Anxiety is normal! – Becomes D/O when excessive fear or excessive anxiety impact daily functioning o Separation Anxiety Disorder – Normal (developmentally appropriate): infants, loss or parent (death or separation), involved in event (witnessed sibling loss, lost in store, kidnapped). Should resolve and normalize with counseling. May continue to experience when related events occur. § Developmentally inappropriate when the following occurs for more than 4 weeks (children/adolescents) • Recurrent excessive distress in anticipation or when experiencing separation • Excessive worry about losing attachment figures • Excessive worry about adverse event (getting lost, kidnapped, illness, ect. Causing separation) • Reluctance to leave attachment figures • Nightmares • Somatic symptoms § Potential DD – other anxiety d/o, panic d/o, depression or mood d/o, conduct d/o, oppositional defiant d/o, personality d/o § Treatment – Cognitive Behavior Therapy (CBT) – talk therapy with processing component or play therapy – based on age § Refer for therapy § Prognosis – EXCELLENT – may continue w/excessive trauma, usually experience periods of exacerbation and remission, but typically resolves by adulthood o Phobia – Marked fear or anxiety r/t specific object or situation. Fear may be expressed by crying, tantrums, freezing or clinging. Object almost always provokes immediate distress and is likely avoided at all cost. Symptoms must last ≥ 6 months for diagnosis § Potential DD – Separation anxiety d/o, social anxiety d/o, panic d/o, OCD, agoraphobia (fear of crowds, public places, open areas) don’t want to leave the home. § Stastics – 5% of children affected (typically have underlying psych component), 60% greater risk of suicide (potentially r/t comorbidity § Treatment – CBT/desensitization § Prognosis – Favorable – except r/t traumatic event (fire) o Social Anxiety D/O -Excessive fear or anxiety of being scrutinized in social situations; fear of appearing anxious and being humiliated, embarrassed or rejected; exhibited by crying, tantrums, freezing, clinging, or selective mutism. Associated with somatic symptoms. § Potential DD – Normal shyness, other anxiety d/o, panic d/o, depression or other mood d/o, autism spectrum d/o, personality d/o § Refer for evaluation and individual and or group therapy (group therapy very effective is child is ready). § Treatment – SSRI – consider risk vs. benefit – start low – go slow § Prognosis – 30% remission w/in one year, 50% remission w/in a few years, 60% of individuals w/out treatment do not show improvement for several years or much longer o Panic Disorder – Recurrent unexpected panic attacks (palpitations, rapid heart rate, sweating and/or chills, shaking, SOB, dizziness, nausea, numbness, light-headed, fear of dying). Severe anxiety causing physical symptoms that can not be controlled by the individual affected. § DX: at least 1 attack must be followed by 1 month of: persistent fear of having another panic attack OR a maladaptive change in behavior r/t the attacks. Important to identify between “panic attack” and severe anxiety, must exhibit physical uncontrollable symptoms. § DD’s – other anxiety d/o, substance induced anxiety d/o § Treatment – Refer for evaluation and individual therapy, tx w/SSRI may be beneficial – weigh risk vs. benefit – start low, go slow o Generalized Anxiety D/O – Persistently on edge, “worry wart”, their worry is typically much more serious than their age or developmental level should express. § Present w/ : Excessive anxiety or worry more days than not; Difficult to control; restlessness, keyed up, on edge; easily fatigued; poor concentration; irritable; muscle tension; sleep disturbance; may have been referred for attention issues. § DD’s – other anxiety d/o, OCD, PTSD, adjustment d/o, depressive d/o § Tx: Refer for CBT; tx with SSRI may be beneficial – consider risk vs. benefit. Start low, go slow § Prognosis – 3% prevalence. Often long-term and difficult to treat o Adjustment D/O with Anxiety – something unusual or negative happens (event triggers mental health issues), develop psych symptoms as result. i.e. move, new sibling, parent w/health issues. § Symptoms occur as result of event. Move triggers anxiety – Diagnose Adjustment D/O w/anxiety. § If anxious w/out trigger – Diagnose Anxiety D/O o Selective Mutism – Consistent failure to speak in situation where there is an expectation for speaking, speaking in other situations, interferes with education and social communication, Duration ≥ 1 month § Prevalence – Very Rare (0.03% - 1% of population) § DD’s – communication d/o, neurodevelopmental d/o, social anxiety d/o, trauma d/o § Prognosis – Generally “outgrown” but other anxiety symptoms may continue to adulthood § Treatment – Refer for CBT, SSRI might be beneficial – consider risk vs. benefit, start low and go slow • Obsessive-Compulsive D/O – 2 key components o Obsessions – intrusive and unwanted, recurrent and persistent thoughts, urges or images, that cause marked anxiety or distress o Compulsions – repetitive behaviors aimed at preventing or reducing anxiety or preventing a dreaded event. The behaviors are excessive and not connected in a realistic way with what they are expected to prevent. Result aimed at preventing anxiety r/t obsession § DD’s – Anxiety d/o, depression or other mood d/o, trauma disorder § Treatment – Refer for CBT, SSRI may be beneficial, start low and go slow, risk vs. benefit Prognosis – Long term chronic illness w/ periods of exacerbation alternating with periods of improvement, complete remission of symptoms is unusual, some improvement with treatment • Mood Disorders o Major Depressive D/O (MDD) – Overwhelmingly Depressed mood most of the day most days (may be expressed as irritability). Decreased interest/pleasure. Appetite changes (dec or inc, with or w/out loss or gain). Sleep changes (insomnia or hypersomnia). Fatigue/decreased energy. Guild/feeling worthless/hopeless. Attention/concentration difficulty. Thoughts of death or suicidal thoughts w/ or w/out plan § Watch for: doesn’t like to have fun anymore, parent describes isolation § DD’s – Adjustment d/o w/ depressed mood, other depressive d/o, bipolar d/o, ADHD, disruptive mood d/o § Treatment – Refer for individual/family therapy, SSRI may be beneficial – consider risk vs benefit, start low, go slow § Prognosis – 10% recover spontaneously w/in 3 months, 40% recover w/in 1st year, at 12 months 50% remain clinically depressed – w/out treatment. Risk of suicide 3% over 10 years. 30% of cases have recurrences w/in 5 years. With each successive depressive episode, the patency of psychosocial factors necessary to trigger new episode decreases, suggesting that repeated depressions do in fact increase a person’s vulnerability to become depressed. With each episode the r/o another episode increases. o Persistent Depressive D/O (Dysthymia) – Depressed mood most of the day, most days, for at least 1 year. Same symptoms as listed under MDD but lasting more than 1 year. VERY difficult to treat, almost engrained in their personality “Eeyore” § DD’s – MDD, Bipolar D/O § Tx – Refer for individual/family therapy, SSRI may be beneficial, consider risk vs. benefit, start low – go slow. Can help a little but never really completely resolves. § Prognosis – Long-term symptoms impacting social and functional ability in up to 80%. Incidence of suicide in 3-12%. § Double depression possible – persistent depressive d/o w/ accompanying major depression Treating Depression & SSRI use from readings • Pediatric Depression should be treated in an integrated fashion seeking help of therapists, social workers, and/or case managers when possible. • Psychotherapy and psychoeducation, regular exercise, healthy diet, and good sleep hygiene, as well as family therapy and support organizations can be paramount in helping adolescents conquer depression • SSRI’s are 1st line in pharmacology treatment (see chart below) o ONLY SSRI FDA approved for pediatric patients are Fluoxetine (Prozac) and Escitalopram (Lexapro) with Fluoxetine being used more frequently. § Fluoxetine – start at 5-10mg daily and titrate up at 2-week intervals based on clinical response, up to target range of 20-80mg dialy. o Citalopram (Celexia) and Sertraline (Zoloft) are also frequently used off label in pediatrics with good effect. Once starting SSRI check in monthly to screen for S/E’s and check for efficacy of current dose. Common S/E’s: gastrointestinal symptoms (loose stools or constipation, change in appetite, nausea, belly pain), dry mouth, sweating, sleep disturbance, headache, rash, and sexual dysfunction. SSRI’s can be activating – tend to increase energy, however may cause symptoms of agitation and restlessness. Black Box warning with regard to increasing SI related to “disinhibition” with regard to risk-taking behaviors or increased impulsivity. SI must be assessed at every follow-up visit. Discontinuation syndrome can occur with abrupt discontinuation of SSRI’s, titration off the medication is imperative! • Bipolar D/O – Not typically diagnosed in patient under 18 yo § Bipolar 1 D/O – presence of manic episode, does not need to have identified depressive episode. • Manic episode - distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased activity or energy, lasting at least 1 week and present most of the day, nearly every day ( or any duration if hospitalization is necessary). • Hypomanic episode - same as above (manic) lasting 4 or more days § Bipolar 2 D/O – Current or past hypomanic episode and current or past major depressive episode o Disruptive Mood Dysregulation D/O – New diagnosis in DSM 5 Bipolar in children less than 18yo (look bipolar but don’t want to “label” them yet). Severe recurrent temper outbursts, three or more times a week (verbal or physical), symptoms begin before age 10 – intensity may change but presence noted. Symptoms are present for at least a year. Sad, irritable or angry mood between outbursts. Occurs in multitude of settings – not just at home. Should not be diagnosed before age 6 or after 18. § DD’s – other depressive d/o, bipolar d/o, oppositional defiant d/o, intermittent explosive disorder § Tx – refer for individual/family therapy, SSRI may be beneficial (with heightened caution – SSRI may precipitate a manic episode). Carefully weigh risk vs. benefit, start low – go slow § Prognosis – limited studies • Conductive D/O – o Oppositional Defiant D/O (ODD) – characterized by a persistent pattern of disobedience, argumentativeness, angry outbursts, low tolerance for frustration, and a tendency to blame others for misfortunes, large and small (trouble making friends, conflict with adults) o Conduct D/O (CD)– Serious violations of social norms, including aggressive behavior, destruction of property, and cruelty to animals (truancy, runaway, robbery, assault) Serious and persistent patterns of disturbed conduct and antisocial behavior; no appreciation for welfare of another; Little guilt or remorse about harming others; impulsive or bullying behaviors possible; established during primary school years, increased after puberty. Predominantly affect boys; May begin as ODD (childhood) and progress to CD if not treated & over 40% of children with CD may progress to antisocial personality D/O as adults. § Treatment – Vigorous early intervention, assessment and management needed: • Parent management therapy • Multisystem therapy • Multidimensional foster care model • Cognitive problem-solving skills training • Anger control training • Possibly medication § Prognosis -Poor without treatment; Currently 50% of children with conduct D/O continue to have mental health problems into adulthood. • Trauma D/O o Reactive Attachment D/O – Consistent pattern of inhibited emotionally withdrawn behavior toward adult caregivers; seen in children of orphanages or where primary caregiver changes frequently § Rarely/minimally seeks comfort when distressed § Rarely/minimally responds to comfort when distressed § Persistent social and emotional disturbance characterized by • Minimal social/emotional responsiveness to others • Limited positive affect • Episodes of unexplained irritability, sadness, or fearfulness § Child has experience a pattern of extremes of insufficient care as evidenced by (at least 1) • Social neglect or deprivation – basic emotional needs of comfort, stimulation, and affection • Repeated changes of primary caregivers • Rearing in unusual settings (institutions) § Care inconsistencies are responsible for symptoms § Symptoms present before age 5 § Developmental age of at least 9 months § Treatment – No standard treatment – but should involve both the child and the parents or primary caregiver. Goals of treatment are to ensure that the child: • Has a safe and stable living situation – or unable to treat • Develop positive interactions and strengthens the attachment with parents and caregivers • Strategies include: o Encouraging the child’s development by being nurturing, responsive and caring o Providing consistent caregivers to encourage a stable attachment for the child o Providing a positive, stimulating and interactive environment for the child o Addressing the child’s medical, safety and housing needs o PTSD (acute stress disorder) – Exposure to actual or threatened death, serious injury or sexual violation by: § Direct experience § Witnessing experience in person § Learning of the experience of close family member or friend o Acute Stress Disorder – symptoms last 3 days to 1 month after the event: § Involuntary, intrusive memories, dreams &/or flashbacks; efforts to avoid distressing memories; efforts to avoid reminders that trigger memories; inability to experience positive feelings; unable to remember event; sleep problems; irritable behavior, anger, or aggression toward others; hypervigilance/exaggerated startle response; memory/concentration difficulty o PTSD – Symptoms as above – lasting longer than 1 month § Child specific symptoms – Bedwetting, after being toilet trained; forgetting how or being unable to talk; acting out the event during playtime; being unusually clingy with a parent or other adult; may have disconnect amnesia yet be acting out in play, or being thinking about event constantly and be acting out with same symptoms § Referral to Mental Health Provider ASAP – don’t wait § Prognosis – with sensitivity and support of families and appropriate professionals, children with PTSD can learn to cope with the memories of trauma and go on to lead healthy and productive lives. o Adjustment D/O – see w/depression & w/anxiety (above) • Neurodevelopmental D/O – skipped to ADHD, nothing in readings mentioned o Intellectual Disabilities o Communication D/O o ADHD – A persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development § Symptoms: • Inattentive: poor attention/careless errors; poor attention; doesn’t listen; no follow-through on instructions; poor organization; Avoids/dislikes demanding tasks; loses/misplaces items; distractible; forgetful • Hyperactive-Impulsive: Fidgets, squirms; won’t remain seated; running/climbing excessively, extreme restlessness; difficulty staying quiet during activities; acting/feeling as if driven by motor; excessively talking; blurts out answers; can’t take turns; intrudes or interrupts • Combined – symptoms from both categories above • Diagnosis – Symptoms begin in childhood, must be present before age 12. May not be diagnosed until much later; symptoms must be present in more than one setting – home and school; using multiple informants helpful (what do others see subjectively); Strong family history; Connors scale useful; more prevalent in males; Females tend to be less hyperactive; if not stratforward don’t start on meds without psych consult. • Comorbidities – learning/language difficulties; ODD or CD; Anxiety and or depression; Mood disorders; psychotic disorders; mental retardation/ low-level functioning; pervasive developmental disorders; smoking/substance abuse; Tic disorder; poor peer relationships; risk for injuries • Differentiating – Attention issues range among a wide range of d/o’s. Why now? Age appropriate behaviors; hearing or vision problems; substance use; life stressors; anxiety; depression; other mood or pysch d/o; if complex REFER o DD’s – ODD, intermittent explosive D/O, other neurodevelopmental d/o, specific learning d/o, intellectual disability, autism, reactive attachement d/o, anxiety d/o, depressive d/o, bipolar, disruptive mood dysregulation d/o, substance use, personality d/o • Treatment – Only if symptoms are impairing function or development o Chronic condition – educate parents and patients, develop partnership with family, develop management plan with targeted goals, include teachers if possible, requires ongoing monitoring and anticipation of developmental changes. o Medication – Always start low and go slow (will add more from readings) o Behavioral therapy ADHD Medication Management - from readings 3 Classes of Meds FDA approved for ADHD • Stimulants – greatest affect- initial medication of choice, short and long acting options o Methylphenidate o Amphetamine Start low, give 3days to 1 week before increasing dose, schedule monthly F/U to monitor S/E’s and track weight, height, pulse, and BP. Until effective dose is found. Then can go to quarterly or by yearly. Preschool-age – Children 3-5yrs with severe ADHD- methylphenidate was effective but in lower dose (2.5mg twice a day) but titrate more slowly and in slower increments than with older children. Adolescents – if substance abuse is present it should be treated before starting ADHD meds. If not achievable then use nonstimulant options (mentioned below). Even if no hx of substance abuse is noted, monitor this age group for misuse Common Side Effects – appetite suppression, weight loss, insomnia, headaches, and abdominal pain. • Atomoxetine (Selective norepinephrine reuptake inhibitor) – should be 1st line of treatment for the following: o Children with co-occurring anxiety o Youth with ongoing substance abuse, possible in house or parental med abuse, or at risk for performance enhancement use o Children whom do not respond to stimulant or exper