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Basics
DESCRIPTION
Behavioral, developmental, or psychosocial problems requiring medical or psychiatric treatment, or causing significant
impairment
EPIDEMIOLOGY
BASICS-EPIDEMIOLOGY-Prevalence
8% of high school students attempt suicide, 25% of whom require medical attention.
Genetics
Strong evidence for heritable/genetic risk of bipolar disorder (manic depression), schizophrenia, and depression
Anxiety, attention deficit/hyperactivity (ADHD), pervasive developmental, and tic disorders also appear to be
genetically transmissible.
Many disorders, e.g., ADHD (3:19:1) and depression (1:2), have distinct male/female preponderance.
Diagnosis
50% of suicide attempters seek medical care in the month preceding their attempt, 25% in the preceding week.
Many patients with psychiatric disorders present with vague physical complaints. All such patients should be
screened for psychiatric problems.
General goals:
1. Goal 1: Assess for safety, i.e., suicidality, homicidality, and adequate support/supervision at home.
2. Goal 2: Rule out organic causes.
3. Goal 3: Establish psychiatric/psychologic causes as possible diagnosis.
4. Goal 4: Work with family to accept possibility of psychiatric/psychologic diagnosis and facilitate referral
to mental health services.
Screening hints:
1. Parents/children are often reluctant to discuss psychosocial issues; they consider them stigmatizing.
Diagnostic and Statistical Manual for Primary Care (DSM-PC), Child and Adolescent version:
1. Collaborative effort of pediatricians and child psychiatrists, psychologists, and neurologists
2. Concise, user-friendly guide for diagnosing mental disorders
SIGNS AND SYMPTOMS
History
SHADSSS mnemonic.
Useful inventory of psychosocial functioning (least threatening topics asked first, most intimate questions asked
last)
All of these areas should be assessed in all patients:
1. School (in school? grades? relationship with peers? teachers?)
2. Home (living situation? relationship with parents? siblings?)
3. Activities (how is free time spent?)
4. Depression
5. Substance abuse (including alcohol/tobacco)
6. Sexuality (including abuse, sexually transmitted diseases, and pregnancy)
7. Safety (suicidality, homicidality, revenge or violent plans)
All families require a family assessment. Families/support systems are crucial to the ultimate success of any
treatment plan.
Goal is to detect any organic causes for patients symptoms (see Differential Diagnosis).
TESTS
No standard battery of laboratory tests. Tests should be ordered based on clinical suspicion.
Specific resources:
1. Screening questionnaires (see Bibliography):
Screening for maternal depression may also be important in detecting psychosocial dysfunction.
Easily scored
CLINICAL:
Pitfalls:
Equating the degree of medical severity of a suicide attempt with the severity of suicide intent:
1. Children/adolescents often misjudge the lethality of their suicide methods.
2. All attempts must be taken seriously.
Delay in diagnosis/referral for treatment (e.g., prognosis for learning disabilities and hearing impairment is
associated with timely intervention)
DIFFERENTIAL DIAGNOSIS
Organic causes:
1. CNS infections or parainfectious syndromes
Glucose
Sodium
Potassium
Calcium
7. Migraines
8. Seizure disorders
9. Hematologic disorders:
Porphyria
Severe anemia
10. Hypoxia
11. Cardiopulmonary disturbances
Tic disorders
Substance abuse
Learning disabilities
Depression
Neglect
Learning disability
Psychotic disorders
Substance abuse
Treatment
MEDICATIONS
Contraindications, precautions, and significant possible interactions
Stimulants:
1. Assessment of growth, heart rate, and BP every 36 months
2. Patients on pemoline should have liver function checked every 612 months.
Tricyclic antidepressants (TCAs): Baseline ECG (before starting TCAs), ECG 1 month after starting TCAs and
every 6 months thereafter
Antipsychotics: Reassessment at 2, 4, and 12 weeks after starting medication, and every 36 months thereafter for
adverse effects, especially dystonia, anticholinergic symptoms, movement disorders
Atypical antipsychotics:
1. Frequently cause significant weight gain and may cause impaired glucose tolerance and prolong QTc
2. Patients weight should be closely monitored, as well as any signs of diabetes mellitus.
3. An ECG should be obtained before and after starting ziprasidone.
Frequently Asked Questions
A: Whenever there is uncertainty about diagnosis or management, or when the treatment needs of the patient
exceed the practitioners capacity to provide them.
Q: How do you get children and families to talk about their problems?
A: There is no trick. Being a patient, empathetic, nonjudgmental listener is the best strategy.
A: Any situation where the safety or functioning of the child, family, or another person is endangered.