Psychiatry [PEDIATRIC PSYCH]

1) Mental Retardation (aka Intellectually Disabled) MR IQ Living Function Grade

Any person with an IQ < 70 (3 standard deviations from the Mild 50-70 Live in Home Work 6th
mean) that occurs before age 18 and impairs functioning. There Alone
are multiple etiologies of mental retardation: chromosomal Moderate 35-49 Live in Home Work 3rd
(Down’s, Fragile X, cri-du-chat) and acquired (maternal Supervised
substance abuse in utero, lead poisoning, and trauma). The Severe 20-34 Institutionalized Basic Ø
important thing with MR is to stratify based on IQ and Function
functionality. In mild MR (50-70) patients are educated to a 6th Profound <20 Institutionalized Care Ø
grade level and can function with minimal supervision (has a
job, lives in a home). Moderate MR (35-49) requires substantial
supervision but can still participate. Severe (30-34) and
Profound (<20) require institutionalized care and constant
supervision. The best thing to do in a patient with MR is begin
immediate education and social skills training once it’s
identified. For genetic causes, prenatal screens and genetic
counseling are critical.

2) Autism
Autism is a disease of impaired speech and social function. The
Autism Asperger’s MR
classic patient is a young patient who exhibits repetitive
behaviors, fails to reach developmental milestones (no social Repetitive Repetitive Ø Repetitive
smile, eye contact, parental bonding) and doesn’t develop ↓Cognition ↓Cognition ↓Cognition
speech. The patient will continually rock back and forth, line up ↓Social Interactions ↓Social Interactions Socially Aware
objects over and over, and seem to be unable to differentiate ↓ Language Intact Language Intact Language
living from non-living objects. There’s no diagnostic test, IQ impaired IQ impaired IQ Impaired
screening test, or treatment. The disease doesn’t manifest until
approximately 3 years of age. The urban legend associating
autism to vaccinations is not true (research is exhaustive). Be
aware that there are two other disease that sounds similar but are
not Autism.

i. Asperger syndrome is Autism with retained language

skills -significantly improving prognosis.
ii. Rett syndrome is a disease of girls who regress after 5
months and progress to death. Genetically inherited,
give genetic counseling to the parents. On a test, if you
see “young girl” and “maybe autism” choose Rett.
3) ADHD
Another disease of unknown etiology that basically sums up a kid
who can’t focus. The diagnosis is clinical and thus has rigid Diagnostic Criteria
criteria. It must be a child <7 years old who has symptoms for >6 (1) Time: >6 months and <7 years old, > 2 settings
months in at least two settings. The “AD” part involves a poor (2) AD: ↓ Attention, inability to finish tasks, easily
attention span; he/she is easily distracted and can’t finish distracted, difficulty following instruction
tasks. This presents as a disruptive student who cannot wait (3) HD: Interruptions, Fidgets, Can’t Wait Turns
his/her turn with poor grades. When delving deeper it’s
apparent there are also symptoms at home (disruptive, running Treatment
all over). Combine this with the “HD” or fidgeting symptoms of (1) Stimulants Methylphenidate / Dextroamphetamine
interruption, breaking rules, and running crazy, it’s ADHD. Help (2) Parental Education
the child focus with psychostimulants (methylphenidate), but (3) Special Education Classes
give it in the morning because it causes insomnia. Help the
parents with patient education on the disease and how to handle
the rambunctious child. Finally, the child may need special
classes; he/she CAN learn, but lack of focus prevents getting
decent grades.
Note – we’re still teaching DSM-IV, as that’s what Step 2
was this year. We’ll be updating to V in 2016.

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 Psychiatry [PEDIATRIC PSYCH]

4) Conduct Disorder Conduct Opposition

Conduct disorder is antisocial personality disorder in a kid. Breaks Laws Ø Breaks Laws
Look for features that demonstrate a disregard for the rights of Harms Animals Ø Harms Animals
others. These are the bullies who pick fights or destroy Bullies Others Ø Bullies Others
property. The biggest tipoff is the killing of animals. Other Lies + Steals Lies + Steals
criminal behavior (lying/stealing) can be seen. This is likely to Defiant to Authority Defiant to Authority
progress to antisocial personality disorder. Attempts at correction
should be made as soon as possible with juvenile detention, big
brother programs, or other behavior modifiers.

5) Oppositional Defiant
If you have a kid who confronts authority (parents, teachers) by
yelling or throwing tantrums, but does NOT break laws and
does NOT hurt others it’s oppositional defiant disorder. What’s
critical is the interaction with peers that separates this from
conduct disorder. They fight, yell, kick, and scream at authority
but play well and interact socially with peers. This disorder
extends from inconsistent parenting; the intervention focuses on
parental education rather than child behavior manipulation. Scores Poorly

6) Learning Disabilities
When a student’s performance is substantially below expected Hearing
for his/her age and grade, usually measured by standardized Vision
testing, it’s time to start fishing. It might be because of medical MR
conditions (MR, Deaf, Blind, Non-English Speaker) or a display
of poor education to date. Therapy to correct medical conditions, Education Correct PRN
remediation, special education, or simply a better student to
teacher ratio may improve performance. ADHD? Seizures?
S Glasses
S
Remediation Special Ed Earpieces
7) Tourette’s Support
Associated with OCD and ADHD, it almost always has an onset
<18. It’s comprised of an anxiety disorder. The impulse to
perform a tic (motor or vocal) becomes overwhelming and
eventually the patient is compelled to act. These may be simple
and hidden (hair flicks, blinking, rubbing) or obvious (vocal).
Vocal tics are rarely swears, but rather usually incomprehensible
noises. Treat with dopamine antagonists. Look for an “ADHD”
kid who gets put on stimulants which then worsens Tourette’s.
Bed Wetting
8) Enuresis
A child who wets the bed first needs to be evaluated for periods
of dryness. If the patient is >4 years old and has been potty- History
trained with periods of dryness consider regression (abuse, new Previously Dry Never Been Dry
sibling) or an anatomical problem (like infection). Screen for s/p toilet trained <7 years old
abuse, educate proper wiping technique for girls, and look for
signs of a UTI. But if a child is past the age of toilet training and Functional Training
has never been dry you need to help them learn. Avoid negative Reinforcement
reinforcement and punishment (they’re probably already U/A S
U/ U/A S
Water Restriction
embarrassed, making them feel worse will make the problem U/S A U/S
Alarm Blankets
worse). Use positive reinforcement; start with nighttime fluid Infxn U/S Mass
restriction, then water alarm blankets, then, if nothing else
works use DDAVP to keep them dry. Remember that a failure to Abx
S Regression Bx
S DDAVP
learn to toilet train is normal up to age SEVEN. Education Resect
S

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