Behavioral Problems and Adolescent Medicine
Dr Collins thinks we should refer for this whole field, not for primary care
ADD/ ADHD
def: persistent, developmentally inappropriate inattention, often c hyperactivity and impulsivity
can exist on its own or as a symptom of other underlying illness
def: neurological disorder and is affected by neurotransmitters
etio: toxin exposure: lead, fetal alcohol syndrome, recurrent infx (OM), visual and hearing problems
etio: poor nutrit (Fe def), tourette's more common than we think, genetics 25% risk with 1st deg relatives,
etio: dep/anx/odd/mania dxs tend to accumulate and compound
etio: abuse, change in home life or living situation
approx 50% risk with homozygotic twins, 33% with dizygotic twins
ddx: seizures esp absence, thyroid problems esp hypo, medication side effects (antiepileptics)
ddx: learning disability
3 types identified: predominantly hyperactive-impulsive, predominantly inattentive, combined
(inattentive kids often missed because they don't get in trouble for being impulsive)
sx: inattention = difficult to keep mind on one task
no trouble with attention if something they really enjoy
easily distracted, difficulty organizing and completing tasks
homework often a big challenge, not successful in school, frustrating place to be
hyperactivity: always on the go, may touch anything and everything
impulsivity: act w/o thinking, inappropriate comments, no regard for consequences
difficult to wait turns, choose the immediate payoff, cannot delay gratification
dx: require pervasive effects in various situations to diagnose ADD/ ADHD
generally expect effects in all parts of life: school, home, social situations
dx: often suggested by teachers rather than parents
dx: probably not best done by primary care doc
neurodevelopmental specialists at medium sized hospitals
also child psychologist or psychiatrist, clinical social worker
dx: symptoms appear before age 7 and persist for at least 6 months (DSM)with sig handicap in at least 2 arenas
tx: standard of care = meds + behavioral counseling and educational interventions
(IEP = individualized educ plan)
many families resist medications, many consider them to be life saving
impossible to say what med will work
MEDS FOR ADD/ADHD
stimulant meds
(gen work on dopamine) can dramatically reduce hyperactivity and impulsivity
long and short acting drugs available
some potential for abuse and addiction
SE's: appetite suppression, headache, insomnia
names: Adderall, Concerta, Cylert, Dexedrine, Dextrostat, Focalin, Metadate ER,
Metadate CD, Ritalin, Ritalin SR, Ritalin LA
alpha-adrenergic agonists
for kids who don’t respond to stimulants
better with hyperactivity and aggression
also used with ADHD along with tics or Tourette
SEs: sedation, depression, hypotension
names: clonidine (Catapres), guanfacine (Tenex)
tricyclic antidepressants
kids who don’t respond to stimulants
ADHD with tics or Tourette
ADHD with anxiety or mood disorders
SE: dry mouth, blurry vision, urinary retention, arrhythmias, fatigue
overdose can be fatal
names: imipramine (Tofranil), Nortryptaline (Pamelor), Desipramine (Norpramin)
Strattera (atomoxetine)
non-stimulant, relatively new, works on norepi
improves attention, concentration, emotional control, decreases restlessness and hyperactivity
benefits: not a controlled substance, no abuse potential, qd dosing
SE: upset stomach, n/v, dizziness, mood swings
OTHER TX FOR ADD/ADHD
she defers to specialist
will do homeopathy but insecure about this alone
occupational therapy-->learning how to learn new skills, how to function
AUTISM SPECTRUM DISORDERS
Autism and Asperger Syndrome are 2 of the 5 pervasive developmental disorders (PVD's)
Autism is at one end of the spectrum; Asperger Syndrome is at the other
generally detected by age 3 if full blown, asperger's detected more at school age
if txd by age of 2 more success
incidence is approx 3.4/ 1000 kids aged 3-10 (new study says 1/34)
signs can be vague and highly variable
watch developmental milestones
sx: deficits in social interaction, verbal and non-verbal communication, repetitive behaviors or interests
kid who just never seemed like other kids,
sx: plateau or loss of skill in social or language development, speech and language delays
not saying at least 1 word by 16 months (usu "no")
failure to combine 2 words by 2 years
if language seems OK, often ability to converse is absent, mb see echolalia
may appear to be intermittently hearing impaired
sx: socially unresponsive, limited eye contact, does not respond to own name, no smile
**lack of one finger point at 1 year (social interaction about outside object: v significant)
do not cuddle; do not respond to cuddling, do not seek comfort or respond to anger/affection appropriately
sx: unusual responses to sensory input
plays with toys oddly or does not know how to play with toys
excessive/obsessive lining up of toys/objects
excessive attachment to single object
TX: refer as early as possible to ped psych, behavioral psych
many kids can learn how to interact socially
for children under 3 years, refer to Early Intervention (county program in many places, free)
decrease frustration by providing ways for kids to communicate, velcro symbols as vocabulary
**1 in 4 kids with ASD have seizures and will require referral to neurologist
2 yrs intensive intervention in preschool years gives good results
CHILD ABUSE/NEGLECT
Child Abuse Prevention and Treatment Act (CAPTA) passed in 74, revised in 96
recognizes a variety of types of child abuse and neglect
neglect = any recent act or failure to act resulting in imminent risk of serious harm, death, serious physical or emotional harm, sexual abuse, or exploitation of a child by a parent or caretaker who is responsible for the child’s welfare
sexual abuse = as employment, use, persuasion, inducement, enticement, or coercion of any child to engage in, or assist any other person to engage in, any sexually explicit conduct or any simulation of such conduct for the propose of any visual depiction of such conduct; or rape, and in cases of caretaker or inter-familial relationships, statutory rape, molestation, prostitution, or other form of sexual exploitation of children, or incest with children
more complete discussion at http://nccanch.acf.hhs.gov/pubs/factsheets/whatiscan.cfm
all 50 states have mandates for reporting of suspected or proven abuse of a child
physicians are required to report
ORS 419B.010 states “Any public or private official having reasonable cause to believe that any child with whom the official comes in contact has suffered abuse, or that any person with whom the official comes in contact has abused a child shall immediately report or cause a report to be made”
members of the general public are also permitted to make reports
reports made in good faith will remain confidential as far as allowable by law
report suspected or known abuse
to local child welfare office, department of human services, local law enforcement agency
phone report is adequate
information they will want:
name and address of child and parents
age of child
type and extent of abuse or neglect
any previous evidence of abuse
any other evidence or information that will help establish the cause of abuse or the identity of the abuser
Office Management of Abuse or Neglect
If a child reports abuse directly to you
tell the child that you believe them, and that you are going to contact people who can help
do not press for details
avoid strong reactions
if parents come to you with a suspicion
listen to their concerns carefully
ask appropriate questions
timing of suspicions
signs and symptoms seen
if they saw signs or if someone else did
possibility of incident happening
other victims?
other kid in household?
try to ensure that it is not a vendetta against an individual or against former spouse/ partner
scenario she has seen: divorce: moms reporting dad's grooming someone, hard to know what to do
refer to appropriate assessor
in Portland metro area, CARES Northwest http://www.caresnw.org
child abuse response and evaluation or something like that
child protection agencies may provide names
get referral network for: child psychologist, psychiatrist, LCSW
some Oregon & national links
Oregon Dept of Human Services
http://www.oregon.gov/DHS/index.shtml
What is Child Abuse (according to Oregon DHS)
http://www.oregon.gov/DHS/abuse/main.shtml
iv. national links
national clearinghouse on child abuse and neglect (stats and info on state laws, other publications)
http://nccanch.acf.hhs.gov/
FBI child pornography reporting site
http://www.fbi.gov/hq/cid/cac/innocent.htm
National assoc of Children’s Hospitals (will have appropriate referral resources)
http://www.childrenshospitals.net/
ADOLESCENT MEDICINE
DEPRESSION
can start any time in childhood
treat it as the serious, potentially life-threatening problem that it is
understand that it is multi-factorial
may have biochemical basis, as with all depression
also has components of family dynamic issues
typically presents as a significant change from previous level of function
sx: sadness or hopelessness, suicide attempts or ideation,
recurrent “accidents”, impaired relationships, poor academic performance,
somatic complaints, school or other activity avoidance, alcohol and drug use,
exacerbation of chronic medical conditions, eating disorders,
behavioral disorders, altered sleep/ eating patterns
signs: sad affect, extreme irritability, anxiety, crying, labile affect or mood,
unexplained exhaustion, self-doubt, low self-esteem, sense of worthlessness,
extreme indecisiveness, guilt feelings, powerlessness, helplessness
tx: appropriate referral essential
maintain trust
maintain as many points of contact as possible: anyone that the child connects with should be in touch often
school counselors
DRUG AND ALCOHOL ABUSE
experimentation is normal for many teens, 80-90%
def of experimentation: used for effect on mood or behav limited to specific situation and not pervasive
habitual use far less common and more worrisome
def of habitual: pattern of ongoing use with compulsive pattern not externally dictated
addiction is also not overly common
def of addiction: only when teen has used drug enough that diminished effects or tolerance
intervention required when substance use affects school, home life
peer circumstances influence what kids will do, how they feel about it, family structure also plays in
hilarious book: "go the fuck to sleep", a kids picture book, about to come out
http://www.amazon.com/Go-F-Sleep-Adam-Mansbach/dp/1617750255
see illustrator's bio he has illustrated books about marijuana: "it's just a plant"
Physician’s role in general practice
the sex-drugs-rock and roll talk
keep tone even, cover everything same as bike helmets
do not try to act like a peer… or a parent
often need to understand school dynamics, peer drug use, the teen’s social life
be realistic and non-threatening
offer facts, not opinion
discuss everything including addiction, brain chemistry and developmment
SEX
teens are generally ready before their parents are even close to understanding
some kids will have parental consent, Dr C enjoys working with realistic families
teens may not consider oral or anal sex to be "sex" (along with Pres Clinton)
discuss everything: birth control, condoms, STDs
essential to be non-judgmental, unbiased
ask the teen about her/his attitudes and beliefs
ask about health classes and their quality
ask about friends, others at school, behaviors the kid has seen or heard about
appropriate referrals: planned parenthood, county health department, school counselors and nurses
"give me your email, I'm going to send you some links" she sends specific links
"what's going on down there" site
she gives her email to kids, they will contact her with questions that way more than by phone
EATING DISORDERS
usu starting in late childhood
Anorexia is more recognizable than bulimia, and getting more common
10-20% male
bulimics often have been purging for a long time before a friend or family member will see obvious signs
some purge after binging, but some purge after most meals
binges usu spontaneous
often disturbed by symptoms
generally ashamed
anorexia often presents with extreme weight loss and disturbed endocrine functions
esophagitis, bleeding, dental enamel erosions, extreme GI complaints
1/3 of anorexics develop bulemia when under tx
probably will be a life time issue, re: food, control, mb cutters too
imp to maintain trust relationship and contact with kid and family
TX: appropriate referral essential to regaining health
both of these are family issues and it takes the whole family to recover
family needs counseling too
Dr Collins thinks we should refer for this whole field, not for primary care
ADD/ ADHD
def: persistent, developmentally inappropriate inattention, often c hyperactivity and impulsivity
can exist on its own or as a symptom of other underlying illness
def: neurological disorder and is affected by neurotransmitters
etio: toxin exposure: lead, fetal alcohol syndrome, recurrent infx (OM), visual and hearing problems
etio: poor nutrit (Fe def), tourette's more common than we think, genetics 25% risk with 1st deg relatives,
etio: dep/anx/odd/mania dxs tend to accumulate and compound
etio: abuse, change in home life or living situation
approx 50% risk with homozygotic twins, 33% with dizygotic twins
ddx: seizures esp absence, thyroid problems esp hypo, medication side effects (antiepileptics)
ddx: learning disability
3 types identified: predominantly hyperactive-impulsive, predominantly inattentive, combined
(inattentive kids often missed because they don't get in trouble for being impulsive)
sx: inattention = difficult to keep mind on one task
no trouble with attention if something they really enjoy
easily distracted, difficulty organizing and completing tasks
homework often a big challenge, not successful in school, frustrating place to be
hyperactivity: always on the go, may touch anything and everything
impulsivity: act w/o thinking, inappropriate comments, no regard for consequences
difficult to wait turns, choose the immediate payoff, cannot delay gratification
dx: require pervasive effects in various situations to diagnose ADD/ ADHD
generally expect effects in all parts of life: school, home, social situations
dx: often suggested by teachers rather than parents
dx: probably not best done by primary care doc
neurodevelopmental specialists at medium sized hospitals
also child psychologist or psychiatrist, clinical social worker
dx: symptoms appear before age 7 and persist for at least 6 months (DSM)with sig handicap in at least 2 arenas
tx: standard of care = meds + behavioral counseling and educational interventions
(IEP = individualized educ plan)
many families resist medications, many consider them to be life saving
impossible to say what med will work
MEDS FOR ADD/ADHD
stimulant meds
(gen work on dopamine) can dramatically reduce hyperactivity and impulsivity
long and short acting drugs available
some potential for abuse and addiction
SE's: appetite suppression, headache, insomnia
names: Adderall, Concerta, Cylert, Dexedrine, Dextrostat, Focalin, Metadate ER,
Metadate CD, Ritalin, Ritalin SR, Ritalin LA
alpha-adrenergic agonists
for kids who don’t respond to stimulants
better with hyperactivity and aggression
also used with ADHD along with tics or Tourette
SEs: sedation, depression, hypotension
names: clonidine (Catapres), guanfacine (Tenex)
tricyclic antidepressants
kids who don’t respond to stimulants
ADHD with tics or Tourette
ADHD with anxiety or mood disorders
SE: dry mouth, blurry vision, urinary retention, arrhythmias, fatigue
overdose can be fatal
names: imipramine (Tofranil), Nortryptaline (Pamelor), Desipramine (Norpramin)
Strattera (atomoxetine)
non-stimulant, relatively new, works on norepi
improves attention, concentration, emotional control, decreases restlessness and hyperactivity
benefits: not a controlled substance, no abuse potential, qd dosing
SE: upset stomach, n/v, dizziness, mood swings
OTHER TX FOR ADD/ADHD
she defers to specialist
will do homeopathy but insecure about this alone
occupational therapy-->learning how to learn new skills, how to function
AUTISM SPECTRUM DISORDERS
Autism and Asperger Syndrome are 2 of the 5 pervasive developmental disorders (PVD's)
Autism is at one end of the spectrum; Asperger Syndrome is at the other
generally detected by age 3 if full blown, asperger's detected more at school age
if txd by age of 2 more success
incidence is approx 3.4/ 1000 kids aged 3-10 (new study says 1/34)
signs can be vague and highly variable
watch developmental milestones
sx: deficits in social interaction, verbal and non-verbal communication, repetitive behaviors or interests
kid who just never seemed like other kids,
sx: plateau or loss of skill in social or language development, speech and language delays
not saying at least 1 word by 16 months (usu "no")
failure to combine 2 words by 2 years
if language seems OK, often ability to converse is absent, mb see echolalia
may appear to be intermittently hearing impaired
sx: socially unresponsive, limited eye contact, does not respond to own name, no smile
**lack of one finger point at 1 year (social interaction about outside object: v significant)
do not cuddle; do not respond to cuddling, do not seek comfort or respond to anger/affection appropriately
sx: unusual responses to sensory input
plays with toys oddly or does not know how to play with toys
excessive/obsessive lining up of toys/objects
excessive attachment to single object
TX: refer as early as possible to ped psych, behavioral psych
many kids can learn how to interact socially
for children under 3 years, refer to Early Intervention (county program in many places, free)
decrease frustration by providing ways for kids to communicate, velcro symbols as vocabulary
**1 in 4 kids with ASD have seizures and will require referral to neurologist
2 yrs intensive intervention in preschool years gives good results
CHILD ABUSE/NEGLECT
Child Abuse Prevention and Treatment Act (CAPTA) passed in 74, revised in 96
recognizes a variety of types of child abuse and neglect
neglect = any recent act or failure to act resulting in imminent risk of serious harm, death, serious physical or emotional harm, sexual abuse, or exploitation of a child by a parent or caretaker who is responsible for the child’s welfare
sexual abuse = as employment, use, persuasion, inducement, enticement, or coercion of any child to engage in, or assist any other person to engage in, any sexually explicit conduct or any simulation of such conduct for the propose of any visual depiction of such conduct; or rape, and in cases of caretaker or inter-familial relationships, statutory rape, molestation, prostitution, or other form of sexual exploitation of children, or incest with children
more complete discussion at http://nccanch.acf.hhs.gov/pubs/factsheets/whatiscan.cfm
all 50 states have mandates for reporting of suspected or proven abuse of a child
physicians are required to report
ORS 419B.010 states “Any public or private official having reasonable cause to believe that any child with whom the official comes in contact has suffered abuse, or that any person with whom the official comes in contact has abused a child shall immediately report or cause a report to be made”
members of the general public are also permitted to make reports
reports made in good faith will remain confidential as far as allowable by law
report suspected or known abuse
to local child welfare office, department of human services, local law enforcement agency
phone report is adequate
information they will want:
name and address of child and parents
age of child
type and extent of abuse or neglect
any previous evidence of abuse
any other evidence or information that will help establish the cause of abuse or the identity of the abuser
Office Management of Abuse or Neglect
If a child reports abuse directly to you
tell the child that you believe them, and that you are going to contact people who can help
do not press for details
avoid strong reactions
if parents come to you with a suspicion
listen to their concerns carefully
ask appropriate questions
timing of suspicions
signs and symptoms seen
if they saw signs or if someone else did
possibility of incident happening
other victims?
other kid in household?
try to ensure that it is not a vendetta against an individual or against former spouse/ partner
scenario she has seen: divorce: moms reporting dad's grooming someone, hard to know what to do
refer to appropriate assessor
in Portland metro area, CARES Northwest http://www.caresnw.org
child abuse response and evaluation or something like that
child protection agencies may provide names
get referral network for: child psychologist, psychiatrist, LCSW
some Oregon & national links
Oregon Dept of Human Services
http://www.oregon.gov/DHS/index.shtml
What is Child Abuse (according to Oregon DHS)
http://www.oregon.gov/DHS/abuse/main.shtml
iv. national links
national clearinghouse on child abuse and neglect (stats and info on state laws, other publications)
http://nccanch.acf.hhs.gov/
FBI child pornography reporting site
http://www.fbi.gov/hq/cid/cac/innocent.htm
National assoc of Children’s Hospitals (will have appropriate referral resources)
http://www.childrenshospitals.net/
ADOLESCENT MEDICINE
DEPRESSION
can start any time in childhood
treat it as the serious, potentially life-threatening problem that it is
understand that it is multi-factorial
may have biochemical basis, as with all depression
also has components of family dynamic issues
typically presents as a significant change from previous level of function
sx: sadness or hopelessness, suicide attempts or ideation,
recurrent “accidents”, impaired relationships, poor academic performance,
somatic complaints, school or other activity avoidance, alcohol and drug use,
exacerbation of chronic medical conditions, eating disorders,
behavioral disorders, altered sleep/ eating patterns
signs: sad affect, extreme irritability, anxiety, crying, labile affect or mood,
unexplained exhaustion, self-doubt, low self-esteem, sense of worthlessness,
extreme indecisiveness, guilt feelings, powerlessness, helplessness
tx: appropriate referral essential
maintain trust
maintain as many points of contact as possible: anyone that the child connects with should be in touch often
school counselors
DRUG AND ALCOHOL ABUSE
experimentation is normal for many teens, 80-90%
def of experimentation: used for effect on mood or behav limited to specific situation and not pervasive
habitual use far less common and more worrisome
def of habitual: pattern of ongoing use with compulsive pattern not externally dictated
addiction is also not overly common
def of addiction: only when teen has used drug enough that diminished effects or tolerance
intervention required when substance use affects school, home life
peer circumstances influence what kids will do, how they feel about it, family structure also plays in
hilarious book: "go the fuck to sleep", a kids picture book, about to come out
http://www.amazon.com/Go-F-Sleep-Adam-Mansbach/dp/1617750255
see illustrator's bio he has illustrated books about marijuana: "it's just a plant"
Physician’s role in general practice
the sex-drugs-rock and roll talk
keep tone even, cover everything same as bike helmets
do not try to act like a peer… or a parent
often need to understand school dynamics, peer drug use, the teen’s social life
be realistic and non-threatening
offer facts, not opinion
discuss everything including addiction, brain chemistry and developmment
SEX
teens are generally ready before their parents are even close to understanding
some kids will have parental consent, Dr C enjoys working with realistic families
teens may not consider oral or anal sex to be "sex" (along with Pres Clinton)
discuss everything: birth control, condoms, STDs
essential to be non-judgmental, unbiased
ask the teen about her/his attitudes and beliefs
ask about health classes and their quality
ask about friends, others at school, behaviors the kid has seen or heard about
appropriate referrals: planned parenthood, county health department, school counselors and nurses
"give me your email, I'm going to send you some links" she sends specific links
"what's going on down there" site
she gives her email to kids, they will contact her with questions that way more than by phone
EATING DISORDERS
usu starting in late childhood
Anorexia is more recognizable than bulimia, and getting more common
10-20% male
bulimics often have been purging for a long time before a friend or family member will see obvious signs
some purge after binging, but some purge after most meals
binges usu spontaneous
often disturbed by symptoms
generally ashamed
anorexia often presents with extreme weight loss and disturbed endocrine functions
esophagitis, bleeding, dental enamel erosions, extreme GI complaints
1/3 of anorexics develop bulemia when under tx
probably will be a life time issue, re: food, control, mb cutters too
imp to maintain trust relationship and contact with kid and family
TX: appropriate referral essential to regaining health
both of these are family issues and it takes the whole family to recover
family needs counseling too
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