Chapter 22 Developmental and Behavioral Disorders 367 Sleep Disorders ■ Essentials of Diagnosis • Night terrors occur in 3% of children usually within 2 hours of falling asleep (deep non–rapid eye movement [REM] sleep) • Night terrors last ~30 minutes with screaming, thrashing, tachyp- nea, tachycardia, sweating, incoherence, sleep walking. Child has no recall of event in the morning • Obstructive sleep apnea—loud snoring, chest retraction, morning headache, dry mouth. Peak age 2–6 years. Associated with ade- noid and tonsillar hypertrophy, obesity, jaw and other facial anom- alies, hypotonia • Dyssomnia—frequent night-time wakening or difficulty falling asleep with frequent demands for parental attention. Usually a learned behavior. Starts at ~9 months of age • Careful physical examination, medical and psychosocial history clarifies diagnosis and establishes parental confidence ■ Differential Diagnosis • Nightmares—frightening dreams during REM sleep. Child is fearful but oriented, seeks parental reassurance, and usually remembers the event the next morning • Exaggerated periodic breathing—may resemble obstructive sleep apnea • Psychiatric problems • GE reflux—sometimes causes night-time wakening because of pain or choking • Hunger—inadequate daytime food/fluid intake associated with night-time demands for food or bottle ■ Treatment • Night terrors—parent education, protection of child during spell, regular sleep schedule, avoidance of sleep deprivation. Scheduled waking of child before spells if night terrors occur predictably • Nightmares—reassurance, night light, establish a routine response to nightmares so child can calm himself/herself when they occur • Dyssomnia—set developmentally appropriate limits on parental visits to the bedroom after child is put in bed, establish regular bed- time rituals with age-appropriate bedtimes, ensure adequate day- time calorie intake, avoid exhaustion • Polysomnography may help clarify diagnosis of obstructive sleep apnea • Treat physical causes of sleep apnea—adenoidectomy, weight reduction ■ Pearl Keeping a tired child awake so he/she can have “quality time” with parents does the child no good and deprives parents of quality time with each other. 22 368 Current Essentials: Pediatrics Temper Tantrums and Breath Holding ■ Essentials of Diagnosis • 50–80% of 1–4 year olds have >1 temper tantrum per week usu- ally provoked by frustration with loss of control • Behavior during tantrum—crying, throwing himself/herself on floor, kicking, screaming, striking people or objects, breath holding spell • Breath-holding spells are reflexive, involuntary, response to anger (child usually cyanotic), surprise, mild injury (child usually pallid). Onset is during expiration • Breath holding may resolve spontaneously or child may experi- ence loss of consciousness, hypotonia, opisthotonos, body jerks, urinary incontinence, hypoxic seizure, or cardiac arrhythmia • Descriptive diagnosis • The prognosis for tantrums and breath holding is good ■ Differential Diagnosis • Breath holding differential includes seizure, cardiac arrhythmia, orthostatic hypotension, iron deficiency anemia, Rett syndrome, familial dysautonomia, lung disease, laryngeal spasm, airway obstruction, tetany • Severe or very frequent temper tantrums suggest underlying devel- opmental disorder, metabolic disease, psychiatric disorder, or autism ■ Treatment • Behavioral treatment of temper tantrums—prevent frustration, use distraction when frustration occurs, stay nearby the child to prevent self-injury, avoid unnecessary conflict, offer choices rather than specific commands • Breath holding—evaluate child for possible organic disorders • If breath holding causes loss of consciousness, put child in lateral position to protect against aspiration and head injury • There are no prophylactic medications for breath holding. Subcutaneous atropine can be given if spells cause bradycardia ■ Pearl Rather than telling a child with temper tantrums that he/she must go to bed now, parents should offer reasonable choices that avoid conflict. “Would you like to read a story or play a game of cards with me before you go to bed?” 22 Chapter 22 Developmental and Behavioral Disorders 369 Attention-Deficit/Hyperactivity Disorder (ADHD) ■ Essentials of Diagnosis • Affects 2–10% of school-age children with a triad of symptoms— impulsivity, inattention, hyperactivity. Substantial genetic com- ponent • Hyperactive impulsive type—fidgetiness, difficulty remaining still, excessive running, climbing and talking, inability to engage in quiet activities, difficulty taking turns, interrupting others • Inattentive type—inattentive to detail, distractible and forgetful; fails to listen, follow instructions, organize tasks, and stay on task; reluctant to engage in tasks; loses utensils • Most children are combinations of the 2 major subtypes ■ Differential Diagnosis • ADHD often associated with/caused by other psychiatric problems— mood disorder, conduct disorder, oppositional defiant disorder, tics, Tourette syndrome • Genetic disorders—fragile X, Williams syndrome, Angelman syndrome, XXY syndrome, Turner syndrome • Brain injury—fetal alcohol syndrome (FAS), prematurity, trauma, hypoxia • Hyperthyroidism, drug abuse, alcohol abuse may resemble ADHD ■ Treatment • Most children improve by 10–25 years of age, though condition may persist into adulthood • Behavior modification usually helps the child with uncomplicated ADHD • Preferential classroom seating, positive reinforcement, consistent structure at home and school, repetition of information, instruc- tion using both visual and auditory modalities • Commonly used medications—methylphenidate, dextroamphet- amine, atomoxetine • Hyper-reactivity and motor tics—clonidine and guanfacine • Tricyclic antidepressants and bupropion sometimes used but the latter may lower seizure threshold ■ Pearl There are many somewhat disobedient or immature school children in whom the diagnosis of ADHD has been made without adequate evalu- ation. Children should not receive powerful medications to eliminate minor behavioral immaturity. 22 370 Current Essentials: Pediatrics Fetal Alcohol Spectrum Disorders ■ Essentials of Diagnosis • FAS—dysmorphic facies (short palpebral fissures, thin upper lip, indistinct or smooth philtrum), growth deficiency and neurode- velopmental abnormalities resulting from intrauterine alcohol exposure • Partial FAS—neurodevelopmental problems without major dys- morphism • Alcohol is a teratogen and may cause congenital anomalies of the heart, skeleton, kidneys, eyes, and ears as well as FAS • The diagnosis rests on history of alcohol use (especially during first trimester) and typical clinical findings ■ Differential Diagnosis • The FAS facies may suggest other syndromes—Williams syn- drome • Consider FAS in children with ADHD • Consider FAS in children with failure to thrive, school failure, depression, panic attacks, anxiety, mood disorders, psychosis ■ Treatment • Prevention of alcohol intake, especially in the first trimester • Methylphenidate for the associated ADHD • Selective serotonin reuptake inhibitors (SSRIs) can help with anx- iety, panic attacks, and depression • Valproate or carbamazepine may be helpful as mood stabilizers • Psychotic features require evaluation and careful selection of therapy ■ Pearl There are no reliable data on exact amount or timing of alcohol con- sumption necessary for teratogenesis or fetal alcohol spectrum disor- ders. Strong evidence indicates that binge drinking during the first trimester is a major risk factor. 22 23 23 Psychiatric Disorders Autistic Disorder 373 Nonautistic Pervasive Developmental Disorders 374 Depression 375 Bipolar Affective Disorder 376 Suicide 377 Schizophrenia 378 Conduct Disorders 379 Anxiety Disorders 380 Obsessive-Compulsive Disorder (OCD) 381 Post-Traumatic Stress Disorder (PTSD) 382 Somatoform Disorders 383 371 Copyright © 2008 by The McGraw-Hill Companies, Inc. Click here for terms of use. This page intentionally left blank Chapter 23 Psychiatric Disorders 373 Autistic Disorder ■ Essentials of Diagnosis • Severe deficits in social responsiveness and interpersonal rela- tionships • Abnormal speech and language development • Behavioral peculiarities—ritualized, repetitive, stereotyped behav- iors; rigidity; poverty of age-typical interests and activities • Onset before age 3 years; male predominance (3:1) • Incidence 16–40/10,000 school-age children • Seizures occur in 30% ■ Differential Diagnosis • Primary associated diseases are—prenatal rubella, phenylke- tonuria, tuberous sclerosis, infantile spasms, postnatal central nervous system (CNS) infections, fragile X syndrome, other meta- bolic disorders • Hearing or visual impairment may mimic autism • Global developmental delay ■ Treatment • No uniformly effective therapy • Early intervention to facilitate development of reciprocal, inter- active, language and social skills • Occupational therapy for sensory integration • Behaviorally oriented special education • Medications to reduce target symptoms—hyperactivity, aggres- siveness, inattention, depression, obsessive behavior, mood swings, self-destructive behavior, stereotypy ■ Pearl The best outcomes occur in children with normal intelligence who have acquired symbolic language skills by age 5 years. One-sixth of autistic children are gainfully employed as adults and one-sixth function in sheltered environments. 23 374 Current Essentials: Pediatrics Nonautistic Pervasive Developmental Disorders ■ Essentials of Diagnosis • Substantial social impairment, either primary or representing loss of previous social skills • Abnormalities of speech and language development or behaviors resembling autism • Milder, more common, and later onset than autism without the complete set of autistic diagnostic criteria • Most Rett syndrome cases are girls with mutation of the MECP2 gene • Childhood disintegrative disorder may start up to age 9 years ■ Differential Diagnosis • Asperger syndrome (male predominance) and Rett syndrome (female predominance) are common primary causes • Developmental speech and language disorders • Hearing impairment • Global developmental delay • Other psychiatric disorders ■ Treatment • Cognitive behavioral therapy to reinforce appropriate social and language skills and behavior • Rett syndrome and childhood disintegrative disorder have worse prognosis than Asperger syndrome • Test and treat for other psychiatric conditions ■ Pearl If a school boy of normal intelligence is socially naive and inept, is picked on by other class members, seems to “walk to a different drum- mer” and has rigidly limited but intense interests, consider Asperger syn- drome. These boys can be helped with accurate diagnosis and social skill therapy. 23 Chapter 23 Psychiatric Disorders 375 Depression ■ Essentials of Diagnosis • Persistent dysphoric mood, mood lability, irritability, or depressed appearance • Neurovegetative signs and symptoms—changes in sleep, appetite, concentration, and activity patterns • Suicidal ideation and feelings of hopelessness • 1–3% incidence before puberty and ~8% in adolescence • Female:Male ratio is equal in preadolescence and increases to 5:1 in adolescence • Patients feel bored, friendless, and isolated. School work may deteriorate • Nonorganic headache, fatigue, abdominal pain, insomnia ■ Differential Diagnosis • Dysthymic disorder has less severe but equally chronic symptoms • Adjustment disorder with depressed mood is a reaction to stress • Hypothyroidism • Substance abuse • Other organic disorders—brain tumor, inflammatory bowel dis- ease, Wilson disease ■ Treatment • Comprehensive care includes immediate therapy of depressive episode, education, and individual and family therapy • Cognitive behavioral therapy may be effective • Medications may be indicated for moderate to severe depression ■ Pearl The adolescent with depression must be monitored long term to iden- tify complications of medication, new life stresses that might precipitate acute deterioration, and additional psychiatric diagnoses especially bipolar disorder. 23 376 Current Essentials: Pediatrics Bipolar Affective Disorder ■ Essentials of Diagnosis • Periods of abnormally, persistently elevated expansive or irrita- ble mood, and heightened levels of energy and activity • Associated symptoms—grandiosity, diminished need for sleep, pressured speech, racing thoughts, impaired judgment • No history of prescribed or illicit drug use • Onset before puberty uncommon; 1% prevalence after puberty; cyclic pattern less prominent than in adults • In 70%, presentation is with depressive symptoms ■ Differential Diagnosis • Attention-deficit/hyperactivity disorder(ADHD) is highly associated • Drug-induced mania or depression • Agitated major depressive disorder • Mood disorder • Physical/sexual abuse or exposure to domestic violence may pro- duce similar symptoms • Hyperthyroidism ■ Treatment • Medical therapy usually necessary—lithium, carbamazepine, val- proate, olanzapine, risperidone are approved drugs • Supportive psychotherapy for patient and family is critical ■ Pearl Although it may be possible to discontinue neuroleptic medication after the acute episode passes, it is usually necessary to continue mood sta- bilizers for a year or even for life. 23 [...]... is often incomplete in children Don’t depend on it 25 394 Current Essentials: Pediatrics Burns ■ Essentials of Diagnosis • • • • • • ■ First degree—injury of superficial epidermal layers is painful, dry, red, hypersensitive, heals with minimal scarring Second degree—superficial partial-thickness injury is red, blistered, painful; deep partial-thickness injury is white, dry, blanches with pressure, decreased... enforcement at presentation Separate child from suspected perpetrator either by hospitaliza- 24 tion or by foster placement until situation clarified Pearl Studies have shown that rolling off the bed or the couch does not cause skull or long bone fractures in infants and children 388 Current Essentials: Pediatrics Sexual Abuse ■ Essentials of Diagnosis Majority of sexual abuse victims have nonspecific physical... antidepressant clomipramine approved for use in adults • ■ Pearl OCD is lifelong but therapy is associated with improved control and remissions in most patients 23 382 Current Essentials: Pediatrics Post-Traumatic Stress Disorder (PTSD) ■ Essentials of Diagnosis • • • • • ■ Differential Diagnosis • • • ■ Reactive attachment disorder may follow infant trauma or neglect OCD Anxiety disorder Treatment •... started immediately upon discovery of nonbreathing child • “Drown-proofing” a child does not replace adequate supervision • • ■ Pearl Children . 3 78 Conduct Disorders 379 Anxiety Disorders 380 Obsessive-Compulsive Disorder (OCD) 381 Post-Traumatic Stress Disorder (PTSD) 382 Somatoform Disorders 383 371 Copyright © 20 08 by The McGraw-Hill. each other. 22 3 68 Current Essentials: Pediatrics Temper Tantrums and Breath Holding ■ Essentials of Diagnosis • 50 80 % of 1–4 year olds have >1 temper tantrum per week usu- ally provoked by. left blank 24 24 Child Abuse Physical Abuse 387 Sexual Abuse 388 Neglect 389 Munchausen Syndrome by Proxy 390 385 Copyright © 20 08 by The McGraw-Hill Companies, Inc. 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