THE PEDIATRICS CLERKSHIP - PART 10 potx

DERMATOLOGIC MANIFESTATIONS OF SYSTEMIC DISEASE See Table 20-4. 380 HIGH-YIELD FACTSDermatologic Disease TABLE 20-4. Dermatologic manifestations of systemic disease. Tuberous sclerosis Ⅲ Ash leaf—hypopigmented lesions anywhere on body Ⅲ Shagreen patches—raised patches on lower back with orange-peel texture Ⅲ Adenoma sebaceum—red, vascular nodules on face that may resemble aggravated acne Ⅲ Periungual fibromas Neurofibromatosis Ⅲ Café-au-lait spots—flat, sharply demarcated, ovoid, light brown macules, with the long axis oriented along a cutaneous nerve track Sturge–Weber Ⅲ Port-wine stain—hemangioma variant; appears as a sharply marginated, red or purple syndrome macule, commonly distributed unilaterally on the face; present at birth and never disap- pears; lesion grows proportionately to the size of the individual and may develop papular and nodular areas (see Figure 20-13) Bacterial endocarditis Ⅲ Osler’s nodes—tender, violaceous subcutaneous nodules on palms and soles Ⅲ Janeway lesions—multiple, hemorrhagic, nontender macules on fingers and toes Ⅲ Subungual splinter hemorrhages Ⅲ Multiple, nonblanching red macules (petechiae) on upper chest and mucous membranes Obesity, endocrino- Ⅲ Acanthosis nigricans—velvety, hyperpigmented plaques; occur in axillae and groin pathy, malignancy (GI) Peutz–Jeghers Ⅲ Lentigines—hyperpigmented macules on nose, mouth, oral cavity, hands, and feet syndrome 381 PSYCHIATRIC EXAMINATION OF CHILDREN Ⅲ Consult multiple sources: Ⅲ Child—young children usually report information in concrete terms but give accurate details about their emotional states Ⅲ Parents Ⅲ Teachers Ⅲ Child welfare/justice Ⅲ Methods of gathering information: Ⅲ Play, stories, drawing Ⅲ Kaufman Assessment Battery for Children (K-ABC)—intelligence test for ages 2 1 ⁄2 to 12 Ⅲ Wechsler Intelligence Scale for Children–Revised (WISC-R)—intelligence quotient (IQ) for ages 6 to 16 Ⅲ Peabody Individual Achievement Test (PIAT)—tests academic achievement MENTAL RETARDATION (MR) See chapter on neurologic disease. LEARNING DISORDERS See chapter on neurologic disease. BEHAVIORAL DISORDERS DEFINITION Behavioral disorders include oppositional defiant disorder and conduct disorder. Oppositional Defiant Disorder (ODD) D IAGNOSIS Ⅲ Recurrent pattern of negativistic, defiant, disobedient, and hostile behavior for 6 months, with four or more of the following: HIGH-YIELD FACTS IN Psychiatric Disease Ⅲ Loses temper Ⅲ Argues with adults Ⅲ Refuses to comply with adult requests or rules Ⅲ Deliberately annoys Ⅲ Does not take responsibility for mistakes or behavior Ⅲ Sensitive, touchy, easily annoyed Ⅲ Angry, resentful Ⅲ Spiteful, vindictive Ⅲ Behavior causes impairment in social and academic functioning. Ⅲ Rule out other causes of clinical presentation. P ATHOPHYSIOLOGY Low self-esteem, low frustration tolerance, precocious use of substances. E PIDEMIOLOGY Ⅲ 2–16% prevalence Ⅲ May be a precursor of a conduct disorder Ⅲ Increased incidence of substance abuse, mood disorders, attention deficit–hyperactivity disorder (ADHD) T REATMENT Ⅲ Behavioral therapy, problem-solving skills Ⅲ Family involvement, parenting skills training regarding limit setting and consistency Conduct Disorder D IAGNOSIS A pattern of behavior that involves violation of the basic rights of others or of social norms and rules, with at least three of the following in 1 year: Ⅲ Aggression toward people and animals Ⅲ Destruction of property Ⅲ Deceitfulness Ⅲ Serious violation of rules E TIOLOGY Involves genetic and psychosocial factors. E PIDEMIOLOGY Ⅲ 6–16% in boys, 2–9% in girls Ⅲ Up to 40% risk of developing antisocial personality disorder in adulthood Ⅲ Increased incidence of ADHD, learning disorders, mood disorders, substance abuse, and criminal behavior in adulthood T REATMENT Multimodal: Ⅲ Structured environment, firm rules, consistent enforcement Ⅲ Psychotherapy—behavior modification, problem-solving skills Ⅲ Adjunctive pharmacotherapy may help—antipsychotics, lithium, selec- tive serotonin reuptake inhibitors (SSRIs) 382 HIGH-YIELD FACTSPsychiatric Disease A 9-year-old boy’s mother has been called to school because her son is defiant toward the teacher and does not comply with her requests to follow the rules. His behavior is appropriate toward his classmates. Think: Oppositional defiant disorder. Typical Scenario Temper tantrums and breath holding are manipulative behaviors. ODD can be a developmental antecedent to conduct disorder. The former does not involve violation of the basic rights of others. A 9-year-old boy’s mother has been called to school because her son has been hitting other children and stealing pens. She reports that he often pokes their family cat with sharp objects. Think: Conduct disorder. Typical Scenario ATTENTION DEFICIT–HYPERACTIVITY DISORDER (ADHD) DEFINITION Three types predominantly: Ⅲ Inattentive Ⅲ Hyperactive–impulsive Ⅲ Combined D IAGNOSIS Ⅲ Six or more of the following for 6 months: Ⅲ Inattention—problems listening, concentrating, paying attention to details, organizing tasks, easily distracted, forgetful Ⅲ Hyperactivity–impulsivity—unable to inhibit impulses in social behavior, leading to blurting out, interrupting, fidgeting, leaving seat, talking excessively Ⅲ Onset before age 7 years Ⅲ Behavior inconsistent with age and development Ⅲ Impairment in two or more social settings. Ⅲ Evidence of impairment in functioning. Ⅲ Rule out other causes of the clinical presentation. Ⅲ The above may lead to: Ⅲ Difficulty getting along with peers and family Ⅲ School underachievement secondary to poor organizational skills Ⅲ Poor sequential memory, deficits in fine motor skills E TIOLOGY Ⅲ Genetic predisposition Ⅲ Perinatal complications, maternal nutrition and substance abuse, ob- stetric complications, viral infections Ⅲ Neurochemical/neurophysiologic factors Ⅲ Psychosocial factors, including emotional deprivation and parental anxiety and inexperience P ATHOPHYSIOLOGY Ⅲ Catecholamine hypothesis, a decrease in norepinephrine metabolites Ⅲ Hypodopaminergic function, low levels of homovanillic acid E PIDEMIOLOGY Ⅲ Three to ten percent prevalence among young and school-age children. Ⅲ Male-to-female ratio: 3:1. Ⅲ Increased incidence of mood disorders, personality disorders, conduct disorder, and ODD. Ⅲ Most cases remit in adolescence; 20% have symptoms into adulthood. T REATMENT Ⅲ Pharmacotherapy: Ⅲ Psychostimulants—methylphenidate (Ritalin), dextroamphetamine, pemoline Ⅲ Tricyclic antidepressants (TCAs), SSRIs Ⅲ Psychotherapy—behavior modification Ⅲ Parental counseling—positive reinforcement, firm nonpunitive limit setting, reduce external stimulation Ⅲ Group therapy—social skills, self-esteem 383 HIGH-YIELD FACTS Psychiatric Disease Conduct disorder is the most common diagnosis in outpatient psychiatry clinics. The three cardinal signs of ADHD: Ⅲ Inattention Ⅲ Hyperactivity Ⅲ Impulsivity Symptoms must be present in two or more situations for a diagnosis of ADHD. A 9-year-old boy’s mother has been called to school because her son has not done his homework. He claims that he did not know about the assignments. He interrupts other kids and is always getting up during class. Think: ADHD. Typical Scenario Onset of ADHD occurs no later than age 7 years. PERVASIVE DEVELOPMENTAL DISORDERS (PDD) DEFINITION Ⅲ Group of conditions that involve problems with social skills, language, and behaviors Ⅲ Apparent early in life with developmental delay involving multiple areas of development Ⅲ Include autistic disorder, Asperger’s syndrome, Rett syndrome, and childhood disintegrative disorder T REATMENT Ⅲ There is no cure, but goal of treatment is to manage symptoms and improve social skills. Ⅲ Remedial education. Ⅲ Behavioral therapy. Ⅲ Neuroleptics such as haloperidol to control self-injurious and aggressive behavior and mood lability. Ⅲ SSRIs to help control stereotyped and repetitive behaviors. Autistic Disorder D IAGNOSIS Ⅲ Diagnosis made within the first 3 years and other causes of the clinical presentation ruled out Ⅲ At least six of the following (with at least two from qualitative impairment in social interaction, one from qualitative impairments in communication, and one from patterns of behavior): Ⅲ Qualitative impairment in social interaction (at least two): Ⅲ Marked impairment in the use of multiple nonverbal behaviors, including poor eye contact Ⅲ Failure to develop peer relationships and attachments Ⅲ Lack of spontaneous seeking to share enjoyment, interests, achievements Ⅲ Lack of emotional or social reciprocity Ⅲ Qualitative impairments in communication (at least one): Ⅲ Delay or lack of spoken language (expressive language deficit) Ⅲ Marked impairment in the ability to initiate or sustain a conversa- tion with others Ⅲ Stereotyped and repetitive use of language or idiosyncratic language Ⅲ Lack of spontaneous make-believe play or social initiative Ⅲ Repetitive and stereotyped patterns of behavior and activities (at least one) Ⅲ Inflexible rituals Ⅲ Preoccupations Ⅲ Highly responsive to intimate environment, stimulus overselectivity, unable to cope with change in routine E TIOLOGY Ⅲ Genetic predisposition (36% concordance rate in monozygotic twins, 0% in dizygotic twins) Ⅲ Prenatal neurologic insult Ⅲ Immunologic and biochemical factors 384 HIGH-YIELD FACTSPsychiatric Disease ADHD is the most common significant behavioral syndrome in childhood. Two thirds of children with ADHD also have conduct disorder or ODD. The most efficacious pharmacotherapeutic agents for ADHD are psychostimulants, though behavioral modification and firm limit setting should also be used. Seventy-five percent of patients have significant improvement on Ritalin. Stimulants used appropriately for ADHD do not cause addiction. Two areas are particularly affected in autistic disorder: Ⅲ Communication Ⅲ Social interactions PATHOPHYSIOLOGY Ⅲ Neuroanatomic structural abnormalities Ⅲ Abnormalities in dopamine and serotonin system—increase in serotonin E PIDEMIOLOGY Ⅲ 10 to 15:10,000 Ⅲ Male-to-female ratio: 4:1 Ⅲ Onset—first year (25%), second year (50%), after 2 years (25%) Ⅲ Significant comorbidity with fragile X syndrome, tuberous sclerosis, mental retardation, and seizures P ROGNOSIS Depends on presence or absence of underlying disorder and speech. Asperger’s Syndrome D IAGNOSIS Ⅲ Impaired social interaction (at least two, similar to autistic disorder) Ⅲ Restricted or stereotyped behaviors, interests, or activities E PIDEMIOLOGY Male > female. Rett Syndrome D IAGNOSIS Ⅲ Normal pre- and perinatal development until between 5 and 48 months of age Ⅲ Normal head circumference at birth, but decreases rate of growth between the ages of 5 and 48 months Ⅲ Loss of previously learned purposeful hand skills between the ages of 5 and 30 months, followed by the development of stereotyped hand movements Ⅲ Early loss of social interaction, usually followed by subsequent improvement Ⅲ Problems with gait or trunk movements Ⅲ Severely impaired language and psychomotor development E PIDEMIOLOGY Classically restricted to females; males are beginning to be recognized due to genetic testing. Childhood Disintegrative Disorder D IAGNOSIS Ⅲ Normal development in the first 2 years of life Ⅲ Loss of previously acquired skills in at least two of the following: Ⅲ Language Ⅲ Social skills Ⅲ Bowel or bladder control Ⅲ Play Ⅲ Motor skills 385 HIGH-YIELD FACTS Psychiatric Disease Half of children with autistic disorder never speak. Those with autistic disorder who do speak exhibit echolalia, pronoun reversal, inappropriate cadence or intonation, impaired semantics, and failure to use language for social interaction. A 3-year-old boy is brought in by his parents because they think he is deaf. He shows no interest in them or anyone around him and speaks only when spoken to directly. He often lines his toys up in a straight line. Hearing tests are normal. Think: Autism. Typical Scenario Computed tomography (CT) and magnetic resonance imaging (MRI) in autistic disorder show ventricular enlargement; polymicrogyria; and small, densely packed, immature cells in the limbic system and cerebellum. Ⅲ At least two of the following: Ⅲ Impaired social interaction Ⅲ Impaired use of language Ⅲ Restricted, repetitive, and stereotyped behaviors and interests E PIDEMIOLOGY Ⅲ Onset ages 2 to 10 years Ⅲ Four to eight times higher incidence in boys Ⅲ Rare TIC DISORDERS Tics Ⅲ Involuntary movements or vocalizations. Ⅲ Most common motor tics involve the face and head (e.g., blinking of eyes). Ⅲ Examples of vocal tics include coprolalia (repetitive speaking of ob- scene words) and echolalia (exact repetition of words). Tourette’s Disorder D IAGNOSIS Ⅲ Multiple motor and vocal tics occurring multiple times per day, almost daily for > 1 year (no tic-free period for > 3 months) Ⅲ Onset before age 18 Ⅲ Distress or impairment in social functioning E PIDEMIOLOGY Ⅲ Three times more common in boys Ⅲ Onset usually between the ages of 7 and 8 years Ⅲ High comorbidity with obsessive–compulsive disorder (OCD) and ADHD E TIOLOGY Ⅲ Genetic—50% concordance rate in monozygotic twins, 8% in dizygotic Ⅲ Neurochemical—impaired regulation of dopamine in the caudate nu- cleus T REATMENT Ⅲ Pharmacotherapy—haloperidol or pimozide Ⅲ Supportive psychotherapy ELIMINATION DISORDERS Enuresis D IAGNOSIS Ⅲ Lack of involuntary urinary continence beyond age 4 for diurnal enuresis and age 6 for nocturnal enuresis Ⅲ Occurs at least twice per week for at least 3 consecutive months Ⅲ Types: Ⅲ Primary—child never established continence Ⅲ Secondary—most commonly occurs between ages 5 and 8 years Ⅲ Rule out the influence of a medical condition (e.g., urethritis, diabetes, seizures) 386 HIGH-YIELD FACTSPsychiatric Disease Unlike those with autistic disorder, children with Asperger’s syndrome have normal language and cognitive development. A 13-year-old boy has had uncontrollable blinking since he was 9 years old. Recently, he has noticed that he often involuntarily makes a barking noise that is embarrassing. Think: Tourette’s disorder. Typical Scenario Tics in Tourette’s disorder may be consciously repressed for short periods of time. Seventy percent of children with autistic disorder are mentally retarded, though a few have narrow remarkable abilities (savants). Only 1–2% can function completely independently as adults. ETIOLOGY Ⅲ Genetic predisposition Ⅲ Physical factors—small bladder, low nocturnal levels of antidiuretic hormone (ADH) Ⅲ Delayed or stringent toilet training Ⅲ Psychosocial stressors E PIDEMIOLOGY Ⅲ 7% male and 3% female prevalence at 5 years old Ⅲ 3% male and 2% female prevalence at 10 years old S IGNS AND SYMPTOMS Urination during the day, night, or both on the individual. T REATMENT Ⅲ According to specific causative factors suggested by an adequate psychosocial evaluation. Ⅲ Enlist child in cure, offer positive reinforcement, do not punish; older children participate in cleaning up. Ⅲ No liquids after dinner; urinate before going to bed. Ⅲ Behavior modification therapy (e.g., buzzer to wake up child when wet- ness is detected). Ⅲ Pharmacotherapy—antidiuretics (DDAVP) or TCAs (imipramine). Encopresis D IAGNOSIS Ⅲ Repeated passage of feces into inappropriate places (e.g., clothing or floor) whether involuntary or intentional. Ⅲ At least one such event a month for at least 3 months. Ⅲ Individual must be at least 4 years old. Ⅲ Rule out the influence of a medication or a general medical condition (e.g., hypothyroidism, lower gastrointestinal [GI] problems, dietary factors). E TIOLOGY Ⅲ Anxiety about defecating in a particular place Ⅲ A more generalized anxiety in response to stressful environmental factors Ⅲ Oppositional behavior Ⅲ Physiologic conditions—lack of sphincter control, constipation with overflow incontinence E PIDEMIOLOGY Ⅲ One percent prevalence in 5-year-old children. Ⅲ Incidence decreases with age. Ⅲ More common in males than females. Ⅲ Associated with other conditions such as conduct disorder and ADHD. T REATMENT Ⅲ According to the specific causative factors suggested by an adequate psychosocial evaluation. Ⅲ Enlist child in cure, positive reinforcement; do not punish. Ⅲ Older children participate in cleaning up. Ⅲ Choose a specific time every day to attempt bowel movement. Ⅲ Stool softeners, if related to constipation. Ⅲ Psychotherapy, family therapy, and behavioral therapy. 387 HIGH-YIELD FACTS Psychiatric Disease Most cases of enuresis spontaneously remit by age 7. Encopresis in a 7-year-old child likely indicates a more serious disturbance than thumb-sucking in a 4-year- old, which is more serious than a nightmare in a 5- year-old, breath-holding spells in a 2-year-old, and nocturnal enuresis in a 6- year-old. MOOD DISORDERS Major Depressive Disorder (MDD) D EFINITION Ⅲ Pathologic sadness or despondency not explained as a normal response to stress and causing an impairment in function Ⅲ Recurrent condition that generally continues into adulthood E TIOLOGY/PATHOPHYSIOLOGY Ⅲ Genetic predisposition. Ⅲ Catecholamine hypothesis: Depression is caused by a deficit of norepinephrine at nerve terminals throughtout the brain. Ⅲ Cortisol hypothesis: Larger quantities of cortisol metabolites in blood and urine, abnormal diurnal variation. E PIDEMIOLOGY Ⅲ Seven percent of general pediatric patients. Ⅲ Twenty-eight percent of child psychiatry clinic patients. Ⅲ Fifteen to twenty percent incidence in adolescents. Ⅲ Two to three times higher in postpubertal girls than boys. Ⅲ Other mental disorders frequently co-occur with major depressive episode including anxiety/panic disorders, OCD, eating disorders, substance abuse, borderline personality disorder, ADHD, and ODD. D IAGNOSIS Ⅲ At least five of the following for a 2-week period: Ⅲ Depressed mood Ⅲ Loss of interest in activities Ⅲ Sleep disturbance Ⅲ Weight change or appetite disturbance Ⅲ Decreased concentration Ⅲ Suicidal ideation Ⅲ Psychomotor agitation or retardation Ⅲ Fatigue or loss of energy Ⅲ Feelings of worthlessness or inappropriate guilt Ⅲ Always rule out other causes of the clinical presentation (e.g., hypothyroidism, nutritional deficiency, chronic infection/systemic disease, substance abuse). C OMPLICATIONS Ⅲ Can persist into adulthood. Ⅲ Up to 15% of patients with depression commit suicide each year. T REATMENT Ⅲ If suicidal or homicidal, admit to the hospital Ⅲ Biopsychosocial approach Ⅲ Individual and/or group therapy Ⅲ Family intervention Ⅲ TCAs, monoamine oxidase inhibitors (MAOIs), SSRIs Ⅲ Electric shock therapy for catatonic syndrome or intractable depression Suicide D EFINITION Ⅲ Suicide is a complex human behavior with biologic, sociologic, and psy- chological roots that results in a self-inflicted death that is intentional rather than accidental. 388 HIGH-YIELD FACTSPsychiatric Disease Fifty to sixty percent of individuals with a single depressive episode can be expected to have a second episode. Electroencephalography (EEG) in depression shows decreased slow-wave (delta) sleep, shortened time before onset of rapid eye movement (REM), and longer duration of REM. In suspected cases of depression, be sure to look for other signs or risk factors such as school failure or family history of mental health disorders. A combination of treatments for depression may be necessary. Childhood depression should be treated with behavior modification before medication. Ⅲ Suicide ideation, with or without a plan. Ⅲ Suicide gesture—for attention, without intent for death. Ⅲ Suicide attempt. E TIOLOGY Ⅲ Genetic predisposition Ⅲ Psychiatric disorders—correlations of suicidal behavior and mood or disruptive disorders, substance abuse Ⅲ Environmental factors—stressful life events; family disruption due to death or separation, illness, birth, or siblings; peer pressure; physical or sexual abuse Ⅲ Parental influence—psychiatric illness, substance abuse, violence, physical or sexual abuse P ATHOPHYSIOLOGY Multiple abnormalities, which may indicate risk for depression, not directly for suicide: Ⅲ Low levels of cerebrospinal fluid (CSF) 5-hydroxyindoleacetic acid (5- HIAA), a serotonin metabolite Ⅲ Decreased imipramine binding in the frontal cortex Ⅲ Abnormal dexamethasone suppression tests suggesting presence of hy- pothalamic–pituitary–adrenal axis hyperactivity Ⅲ High levels of cortisol urinary metabolites Ⅲ Enlarged adrenal glands E PIDEMIOLOGY Ⅲ Attempted suicides: Ⅲ 0.7% 5 to 14 years old Ⅲ 13% 15 to 24 years old Ⅲ Third leading cause of death for young adults aged 15 to 24 years old. Ⅲ In the United States, there are about 50 to 200 attempts for each complete suicide. Ⅲ Males more frequently complete suicide, but females attempt more often. Ⅲ The rate of suicide is higher in Alaskan, Asian-American, and Native American youth. Ⅲ Of the 1–2% of those who attempt suicide, 10% will eventually complete the act. Ⅲ Risk factors: Look for psychiatric disorders, family clustering of suicides, substance use/abuse, history of sexual abuse, or serotonin abnormalities. D IAGNOSIS Ⅲ Even though risk factors for suicide are known, it is not possible to pre- dict who will commit suicide. Ⅲ Assess signs and symptoms, correlate with other clinical variables such as psychiatric and substance abuse history, gender, age, race, prior history of suicide attempts, and recent traumatic life events. Ⅲ Key questions: Are you having any thoughts about harming yourself? taking your life? Have you developed a plan? What is your plan? T REATMENT Ⅲ Immediate hospitalization; remove all potentially lethal items. Ⅲ Psychotherapeutic intervention, trustful atmosphere, coping strategies; remove motivation for suicide; involve parents and relatives, guidance counselor. Ⅲ Pharmacotherapy depends on the accompanying diagnosis. 389 HIGH-YIELD FACTS Psychiatric Disease One percent of suicide gestures are lethal. Seventy-five percent of those who go on to attempt suicide convey their suicidal intentions directly or indirectly. Thirty to seventy percent of suicides occur with significant alcohol or drug abuse. Substance abuse disinhibits the individual to complete the act. Suicide completers: male, older, history of depression, alcoholism, schizophrenia, careful planning, high lethality, firearms. Suicide attempters: female, younger, history of depression, alcoholism, personality disorder, impulsive, no planning, low lethality, drug overdose. [...]... of the following: Ⅲ Stated desire to be or that he or she is the other sex Ⅲ Wearing clothes appropriate to the opposite sex Ⅲ Persistent role playing or fantasies of being the opposite sex Ⅲ Interest in the habits of the opposite sex Ⅲ Preference for playmates of the opposite sex Psychiatric Disease HIGH-YIELD FACTS Typical Scenario A 16-year-old girl has a 6month history of amenorrhea and a 25-lb... behind the conscious victim, and wrap your arms around the abdomen 4 Place the thumb of one fist in the midline of the abdomen just above the umbilicus (well below the xiphoid) 5 Grasp the fist with the other hand and deliver quick thrusts inward and upward 6 Continue until object is expelled or victim becomes unconscious Ⅲ If the victim becomes unconscious (witnessed): 1 Place victim supine 2 Open the. .. the airway with head-tilt chin-lift; if you see the object, attempt a finger sweep to remove it 3 Attempt rescue breathing 4 If unsuccessful, reposition head and attempt rescue breathing 5 If still unsuccessful, straddle the victim, placing the heel of one hand on the child’s abdomen in the midline just above the umbilicus (avoiding the xiphoid) 6 Place the other hand on top of the first and deliver... HIGH-YIELD FACTS TREATMENT Ⅲ Long-term therapy is required Ⅲ Maintain a professional distance from the patient Ⅲ Establish ground rules for therapy Ⅲ Behavioral therapy such as self-observation, extinction, operant conditioning, and modeling Ⅲ Pharmacotherapy: Ⅲ First-line agents are SSRIs (i.e., fluoxetine, fluvoxamine, paroxetine, sertraline) Ⅲ Clomipramine is a second-line agent Ⅲ Also lithium, L-tryptophan... year old)—pinch nose and create mouth-to-mouth seal Ⅲ Give two slow breaths (the correct volume is different depending on the size and age of the child—use the rise and fall of the chest wall as a gauge) Ⅲ If the chest does not rise, or the breath does not go in easily, reposition the head and try again 6 Circulation—pulse check in brachial artery for infants and the carotid artery for children > 1... cartilage HIGH-YIELD FACTS Anatomic Differences in the Pediatric Airway Ⅲ Smaller airway Ⅲ Tongue occupies a greater percentage of the oropharynx Ⅲ Vocal cords are more superior and anterior Ⅲ The tonsils and adenoids are more prominent Ⅲ The epiglottis is shorter, stiffer, and more narrow Ⅲ The tracheal rings are less rigid Ⅲ The narrowest part of the airway is just below the vocal cords at the nondistensible... determined by the size of this opening Ⅲ Smaller amounts of vocal cord edema can drastically reduce the diameter of the airway (resistance is inversely proportional to the fourth power of the radius) Ⅲ The angle between the base on the tongue and the glottis is more acute Do not do blind finger sweeps in choking children; do so only if you see the offending object Pediatric Life Support HIGH-YIELD FACTS... or prevent the development of cardiac arrest Improper opening of the airway is the most common cause of ineffective rescue breaths Infant Compressions Two fingers 0.5″–1″ depth Rate > 100 per min 5:1 ratio Pediatric Life Support Infant Compressions For < 1 year of age: Ⅲ Place one hand on the head to maintain open airway for ventilation Ⅲ Place the two middle fingers of the other hand on the sternum... have been abandoned by their parents or were removed from a dysfunctional environment Ⅲ There are 430,000 children in foster care SIGNS AND SYMPTOMS Ⅲ Adolescent curious about his or her origins and early life creates conflict within the individual 403 Psychiatric Disease ETIOLOGY Ⅲ Questions of who the other parents are and why they left him or her and the subsequent impact of the perceived abandonment... assumptions of the behavior and personalities of the people whose union produced the child causes them to be hypervigilant HIGH-YIELD FACTS Malingering DEFINITION Intentional creation of symptoms for secondary gain (e.g., getting out of going to school or doing chores) Ⅲ Ⅲ Ⅲ Ⅲ TREATMENT Ⅲ Individual and family therapy Ⅲ Address disruptive behavior and the etiology Ⅲ Location of birth parents with the agreement . than thumb-sucking in a 4-year- old, which is more serious than a nightmare in a 5- year-old, breath-holding spells in a 2-year-old, and nocturnal enuresis in a 6- year-old. MOOD DISORDERS Major. conduct disorder. The former does not involve violation of the basic rights of others. A 9-year-old boy’s mother has been called to school because her son has been hitting other children and stealing. Long-term therapy is required. Ⅲ Maintain a professional distance from the patient. Ⅲ Establish ground rules for therapy. Ⅲ Behavioral therapy such as self-observation, extinction, operant conditioning,