NR 606 EXAM DIAGNOSIS AND MANAGEMENT YEAR 2024/2025 / ACCURATE CURRENTLY TESTING EXAM VE, Exams of Nursing

Download NR 606 EXAM DIAGNOSIS AND MANAGEMENT YEAR 2024/2025 / ACCURATE CURRENTLY TESTING EXAM VE and more Exams Nursing in PDF only on Docsity! NR 606 EXAM DIAGNOSIS AND MANAGEMENT YEAR 2024/2025 / ACCURATE CURRENTLY TESTING EXAM VERSIONS WITH ACTUAL QUESTIONS AND DETAILED ANSWERS WITH A STUDY GUIDE / EXPORT VERIFIED FOR GURANTEED PASS Steps for Obtaining Informed Consent -Assess pt ability to understand medical info, tx options, to make a voluntary decision. -Present relevant info with accuracy and sensitivity: • diagnosis • nature & purpose of tx options • benefits, risks, burdens of all tx options, including forgoing tx -Document informed consent conversation in the medical record, including all consent forms. Underlying assumptions for child and adolescent psychotherapy Developmental considerations Family involvement Systems involvement Resiliency Underlying assumptions for child and adolescent psychotherapy: Developmental considerations -developmental level will impact how they: • reason • approach relationships • regulate emotion and behavior • communicate -Developmental considerations • inform the diagnostic process • guide tx planning Underlying assumptions for child and adolescent psychotherapy: Family involvement -Family involvement in tx & decision-making • a norm in child and adolescent psychotherapy -invite parents to share the hx of the child or adolescent's chief complaint & prior tx, medical & developmental hx, & behavioral info privately with the therapist ahead of the session • avoid feelings of criticism or discouragement -collaborate with parent or caregiver as a tx partner Underlying assumptions for child and adolescent psychotherapy: Systems involvement -Therapists must consider the systems that surround children & adolescents & promote their development • family • school • peers • the community -Therapy can help promote the child/adolescent's socioemotional competence -help develop a community support system Underlying assumptions for child and adolescent psychotherapy: Resiliency -therapist work to promote resiliency in children & adolescents • using strength-based orientation -supports: • functioning • self-regulation • deal with challenges they faces Piaget's Stages of Cognitive Development -Sensorimotor stage: Birth-2 yrs • cognitive abilities based on reflexes • object permanence & causality -Preoperational stage: 2-7yrs • can use mental representations, symbolic thought, & language • thinking is egocentric -Concrete operational stage: 7-11yrs • logical operations when thinking/solving problems • thinking is concrete -Formal operational stage: 12yrs+ • Adolescent can use abstract reasoning in addition to logical operations • Child can understand theories, hypothesize, comprehend abstract ideas (love & justice) Screening, Brief Intervention, Referral to Treatment (SBIRT) -Screening • Quickly assesses severity of substance use & ID the appropriate level of tx -Brief intervention • Focuses on increasing insight & awareness regarding substance use & motivation toward behavioral change -Referral • Guidance to tx provides those identified as needing more extensive tx with access to specialty care Medication-Assisted Treatment (MAT) Treatment for opioid use disorder combining the use of medications (methadone, buprenorphine, or naltrexone) with counseling and behavioral therapies. Mental health and youth -13% of children ages 8-15 experience a mental health condition -50% of children ages 8-15 experiencing a mental health condition do not receive tx -13-20% of children living in the U.S. (1 out of 5 children) experience a mental health condition Rationale: Tamika is in the Formal Operational stage. This stage typically occurs at age 12 and up. Adolescents and young adults begin to reason abstractly and can consider hypothetical problems. They begin to think more about moral, philosophical, ethical, social, and political issues. Addressing Parental Concerns: Collaborative Treatment Plans -tx plans for children typically made in collaboration with parents or guardians -Collaboration between the PMHNP, clients, and families when creating the treatment plan is key to ensuring the plan meets the client's needs and is comfortable and manageable for the family Ethical Considerations in the Treatment of Children and Adolescents Privacy and HIPAA Informed Consent Mandatory Reporting Ethical Considerations in the Treatment of Children and Adolescents: Privacy and HIPAA -parents have right to req access to a minor's mental health record, including symptoms, diagnosis, tx plan • circumstances may limit that right ➣see HIPAA fact sheet Ethical Considerations in the Treatment of Children and Adolescents: Informed Consent -Parents may decide whether to allow tx child is unable to provide true informed consent -children may not be able to give legal consent, should be included in discussions about med & tx whenever possible • encourage tx adherence Ethical Considerations in the Treatment of Children and Adolescents: Mandatory Reporting -PMHNPs mandated reporters in most states • required to report suspicions about abuse or neglect to the appropriate authorities -federal & state statutes include stipulations related to mandatory reporting -PMHNPs responsible for following all relevant statutes in their state of practice most common complication during the perinatal period? Mental health problems maternal mental health -Up to 1 in 5 women will suffer from a maternal mental health disorder like postpartum depression -<15% of women receive tx -1 in 7 will experience depression during pregnancy -Up to 50% of women living in poverty will suffer from a maternal mental health disorder -Maternal mental health disorders impact the whole family, not just moms -More than 600,000 women will suffer from a maternal mental health disorder in the U.S. ever year -Anxiety & depression have risen 37% in teen girls. This will increase the number of women suffering postpartum depression in the future -Rates of depression are more than doubled in Black moms due to cumulative effects of stress called weathering Ethical Considerations in Maternal Mental Health Tx -PMHNP must carefully weigh the risks & benefits r/t starting, continuing, switching, or discontinuing med therapy during the perinatal period -work to create tx plans that respect clients' goals & perspectives Prescribing Considerations in Maternal Mental Health Tx -Pharmacologic therapy during pregnancy may be necessary to prevent maternal and fetal harm • health of the embryo or fetus depends on health of the mother -risks and benefits of all psychoactive medications to both the pregnant client and fetus must be considered -risks and benefits of prescribing medications for breastfeeding clients must also be considered • many drugs cross from the maternal circulation into breast milk and may pose harm to the nursing baby Prescribing Considerations in Maternal Mental Health Tx: Pregnancy -Nearly 50% of pregnancies are unplanned -when prescribing for pts of reproductive age take into consideration that pregnancy may occur • initiate discussions about medication safety -may work with the pt 6-12 months before a planned pregnancy to adjust meds as needed -be prepared to provide guidance to pts who have already conceived -Most meds can be continued during pregnancy -if tx plan includes med contraindicated during pregnancy: • discuss pts intended method of birth control • contingency plan for unplanned pregnancy -decision made to D/C medication, drugs should be tapered whenever possible -Communication throughout the pregnancy is crucial to ensure client safety if symptoms worsen -physiologic changes during pregnancy impact pharmacokinetics of many meds • increase blood plasma level may increase the distribution volume of certain meds • Hormonal changes in CYP450 may increase or decrease drug metabolism • Increased renal blood flow & GFR may speed the excretion Prescribing Considerations in Maternal Mental Health Tx: Lack of Evidence -psychoactive medications in the perinatal period • paucity of evidence regarding the true risks for the pregnant client and developing fetus ➣limited as pregnant women and newborns are frequently excluded from medication research Prescribing Considerations in Maternal Mental Health Tx: Switching Medications During Pregnancy -switching meds during pregnancy can create a high risk for destabilization of mental illness • puts both the client and fetus at risk for stress & trauma • increases the absolute # of substances to which the fetus is exposed ➣may increase risk for adverse outcomes -If stable on current med regimen, typically better to continue current regimen Allie is a 26-year-old who has been receiving treatment for bipolar I disorder for 3 years. Her symptoms have been in remission with lithium 500 mg twice daily. She also completed 12 weeks of interpersonal and social rhythm therapy (IPSRT) upon diagnosis and used the life charting methodology to track her symptoms. She calls her PMHNP and states "I just found out I'm pregnant. My partner and I were not expecting this, but we are excited! I am worried about what lithium will do to my baby. Sh schedule an appointment for Allie and her husband to discuss a treatment plan as soon as possible ask Allie to continue taking lithium at the current dose for now recommend that Allie begin tracking her mood, sleep schedule, and other symptoms Rationale: Rationale: The PMHNP should schedule an appointment as soon as possible to discuss Allie's treatment plan during her pregnancy. Discontinuation of medications for pregnancy is associated with a relapse rate of 80-100% for clients who take mood stabilizers; therefore, the client should not abruptly cease taking lithium (Ortega et al., 2023). Clients with a diagnosis of bipolar disorder may benefit from tracking the symptoms of their illness, especially during stressful times. Although reassurance is appropriate, the PMHNP should not minimize the potential risks of continuing medication by telling the client that no harm will come to the baby. Discontinuation of medications for pregnancy is associated with a relapse rate of ___________% for clients who take mood stabilizers 80-100% Informed consent: pregnancy -must initiate discussion with pt regarding informed consent for tx • whether new symptoms during pregnancy or already established with care • risks of continuing current meds and the risks of stopping them -help pt process their risk factors & tx hx to make an informed decision -if must remain on high-risk medications such as valproic acid should be thoroughly evaluated by the multidisciplinary team including a perinatal psychiatrist -Documentation should note whether the woman plans to continue with treatment or discontinue the medication Kenya is a 36-year-old who has been taking fluoxetine for three years for major depressive disorder. Her symptoms are currently in remission, and she just found out that she is 7 weeks pregnant. She calls the PMHNP to discuss whether she should continue her medication during pregnancy. After the discussion, Kenya indicates that she will remain on her medication. Which of the following should be included in the discussion and documentation of the call with Kenya? Select all that apply. rare adverse effect of persistent pulmonary hypertension in the neonate common adverse effect of postnatal abstinence syndrome potential risks of discontinuing treatment to both mother and baby decision to continue treatment Rationale: Although neonatal withdrawal syndrome can occur in newborns who are exposed to second-generation antipsychotics, reducing or discontinuing aripiprazole or switching to another antipsychotic medication may cause destabilization in the client. The infant may need a few days of additional monitoring after delivery, but the client should remain on her optimized dose. psychotropic medications & Breastfeeding -American Academy of Pediatrics advocates breastfeeding through the first 6 months of life -most psychotropic medications pass into breast milk • If infant exposed to med in utero, may discuss continuing med during breastfeeding, unless has severe side effects for infant -req new or additional prescriptions while breastfeeding • discuss whether benefits of breastfeeding outweigh the risks of exposure to the infant • bottle feeding may be the best option -Pts must be educated to support informed choice & their preferences must be supported Safe for Breastfeeding -SSRIs -Benzodiazepines -Valproic acid -Quetiapine Safe for Bottle Feeding -Lithium -Lamotrigine -Clozapine Substance Use Disorders During the Perinatal Period -Perinatal SUDs are an urgent public health crisis • increasing across all groups of childbearing people ➣rates rising rural or low-income communities & those with Medicaid coverage for maternity care -greatest risk for life-threatening outcomes of SUDs is among people of color. -hallmark symptoms of SUDs: behavioral, physical, and psychological dependence -most used substance in the perinatal period is tobacco, followed by alcohol, cannabis, and other illicit drugs • use of prescription & illicit opioids also increasing -In US: 70,000 maternal overdose deaths in 2018, 69% were r/t opioid use Health Risks Associated with SUDs: Tobacco No tobacco product is considered safe for use during the perinatal period -Smoking-related pregnancy complications: • ectopic pregnancy • placental abruption • placenta previa • fetal mortality • stillbirth • preterm birth • low birth weight infants -Smoking-related effects on neonates: • sudden infant death syndrome • birth malformations ➣oral clefts ➣neural tube defects -Smoking-related effects on infants, children, and adolescents: • asthma • cognitive impairment • lower respiratory illness • ADHD • central nervous system tumors Health Risks Associated with SUDs: Alcohol -Drinking while pregnant costs the US $5.5 billion -CDC: no safe time to drink during pregnancy, no safe quantity of alcohol to consume while pregnant or trying to get pregnant -1st trimester exposure correlates with the most significant alcohol-related birth outcomes -increased risk for miscarriage, stillbirth, congenital anomalies, low birth weight, small for gestational age, and preterm delivery -Lifelong effects of AUD on children: • fetal alcohol spectrum disorders (FASDs) • neurodevelopmental & CNS deficits • speech & language challenges • cognitive & behavioral deficits • impaired executive functioning • psychosocial difficulties in adulthood fetal alcohol spectrum disorders (FASDs) Up to 1 in 20 US school children may have FASDs -Physical Issues: • low birth weight and growth. • problems with heart, kidneys, and other organs. • damage to parts of the brain. Leads to... -Behavioral and intellectual disabilities: • learning disabilities and low IQ • hyperactivity • difficulty with attention • poor ability to communicate in social situations • poor reasoning and judgment skills Can lead to... -Lifelong issues with: • school and social skills • living independently • mental health • substance use • keeping a job • trouble with the law Health Risks Associated with SUDs: Cannabis -often combined with other substances -associated with: • preterm labor • low birth weight • small for gestational age deliveries • adverse effects on fetal and adolescent brain growth • adverse effects on executive functioning skills • behavioral problems • adverse effects on academic achievement -All forms of cannabis have adverse effects, even medical marijuana Marijuana Possible Effects on Your Fetus -Disruption of brain development before birth -Smaller size at birth; higher risk of still birth -Higher chance of being born too early, especially when a woman uses both marijuana and cigarettes during pregnancy -Harm from second-hand marijuana smoke: Behavioral problems in childhood and trouble paying attention in school Marijuana Possible Effects on You -Permanent lung injury from smoking marijuana -Dizziness, putting you at risk for falls -Impaired judgment, putting you at risk of injury -Lower levels of oxygen in the body, which can lead to breathing problems Health Risks Associated with SUDs: Cocaine -majority of women addicted to cocaine are of childbearing age -linked with poor pregnancy-related outcomes: • premature rupture of membranes • placental abruption • preterm birth • low birth weight • small for gestational age deliveries, as well -long-term effects in children and adolescents: • lower short-term memory • child and adolescent delinquent behavior • earlier age of sexual activity • substance use Health Risks Associated with SUDs: Opioids -epidemic in the U. S. -Opioid use disorder (OUD) during pregnancy, including heroin & prescription opioids, increases risk of maternal life-threatening health problems & death by 50% -greater risk of eclampsia, heart attack or heart failure, & sepsis women of color substance use during pregnancy: Assessment and Screening -The U.S. Preventative Services Task Force (USPSTF) and ACOG have recommended the Brief Intervention and Referral to Treatment (SBIRT) approach • screen for substance use during the perinatal period -Validated screening tools for substance use during pregnancy • Substance Use Risk Profile-Pregnancy scale (SURP-P) • 4P's Plus ➣can also include validated screening questions for depression & domestic violence SUD Treatment in the Perinatal Period -not contraindicated -associated with better outcomes for both the pregnant person & the fetus -pharmacological & nonpharmacological approaches -Goals of tx: • abstinence or reduction of substance use • prevention of adverse effects due to substance use or withdrawal on the pregnant person & fetus • reduction of high-risk behaviors associated with substance use • improved quality of life & social conditions Perinatal Period: Alcohol Use Disorder Tx -advise pregnant clients who use alcohol to abstain or minimize use during pregnancy and breastfeeding -Behavioral therapy and harm reduction counseling -little info is available of acamprosate and naltrexone safe use during pregnancy -Inpatient tx recommended for pts at risk for moderate, severe, or complicated alcohol withdrawal • indicated by a score of >10 on the CIWA-Ar Perinatal Period: Tobacco Use Disorder Tx -advise clients to discontinue tobacco use during pregnancy -perform or refer clients for psychotherapy & support -review risk & benefits with pt, nicotine replacement therapy (NRT), bupropion, or a combination of these interventions may be initiated • Higher doses of NRT may be req in pregnant pt due to metabolic changes of pregnancy -immediate-release preparations, gum or inhaler, can help minimize infant exposure during pregnancy & breastfeeding -Insufficient evidence for the use of varenicline bupropion exposure in the fetal period is associated with: -slightly elevated rates of congenital heart defects • overall number remains low Perinatal Period: OUD Tx -Clients advised to avoid abrupt discontinuation of opioid use • opioid withdrawal during pregnancy can risk harm to both mother & infant -Methadone & buprenorphine, most prescribed MAT for OUD in pregnancy • Dosing may be increased during 2nd & 3rd trimesters due to increased blood volume & metabolism -Naltrexone not recommended • concerns of detoxification, uncertain safety profile in pregnancy -MAT • continue tX through pregnancy, labor, delivery, postpartum period -Breastfeeding • methadone, buprenorphine, and naltrexone are considered safe full spectrum of perinatal mental health disorders -can occur during pregnancy & the first year postpartum • depression • bipolar II disorder • anxiety • OCD • PTSD • psychosis -mild to severe Anxiety -Increased brain activity in the amygdala & prefrontal cortex -PET scans have also shown reduced serotonin binding in patients with anxiety -GAD • persistent, uncontrollable worrying that causes emotional distress, symptoms on most days, for a period of at least 6 months -Symptoms: • worrying, restlessness, irritability, muscle tension, fatigue, sleep disturbances Risk factors for developing anxiety -genetic predisposition (family history of anxiety) -being female -recent life stressors -chronic physical illness -lack of support during childhood Anxiety meds -Anxiolytic • Buspirone ➣↓ drug interactions ➣↓ adverse effects -SSRIs/SNRIs • escilatopram (Lexapro) • paroxetine (Paxil) • duloxetine (Cymbalta) ➣highly effective ➣↑ drug interactions ➣risk of hyponatremia -Benzodiazepines • alprazolam (Xanax) • clonazepam (Klonopin) ➣multiple adverse effects ➣risk of misuse ➣fall risk ➣highly effective ➣rapid onset ➣can be used PRN Symptoms of Psychosis -Hallucinations • Auditory, Visual, Tactile, Olfactory, Gustatory -Delusions • Persecution, Somatic, Grandeur, Control -Thought Disorder • incoherent speech, loose associations, meaningless words, perseveration -Disorganized behavior • childlike silliness, unpredictable agitation, inappropriate clothing for the weather, poor hygiene Depression -Decreased brain activity in the prefrontal cortex -symptoms that last >2 weeks -Symptoms: • depressed or irritable mood, diminished interest in activities, significant weight or appetite changes, fatigue, feelings of worthlessness, sleep disturbances, diminished ability to concentrate -can be influenced by genetic & environmental factors, stressful life events • giving birth or experiencing emotional trauma -linked to neurotransmitter imbalances prefrontal cortex controls: attention, memory, mood, & personality MDD -primary feature of MDD is the occurrence of at least 1 episode of major depression lasting at least 2 weeks -must experience 5 or more of the following symptoms in 2 weeks to be diagnosed with a major depressive episode: • feeling low most of the day for most days • decreased interest in activities • substantial weight loss, significant change in appetite • fidgeting, random movement (i.e. pacing) Rationale: Valproic acid and its derivatives can cause leukopenia, thrombocytopenia, and hepatotoxicity. Monitor CBC and LFTs every 3 months for 1 year and then annually. Select the lab tests required for Carbamazepine: thyroid function liver function tests (LFTs) renal function hemoglobin A1C (HbA1C) complete blood count (CBC) serum carbamazepine level complete blood count (CBC) liver function tests (LFTs) renal function serum carbamazepine level Rationale: Carbamazepine can cause blood dyscrasias, hepatotoxicity, and renal failure. Oder a CBC, LFT, and renal function every 3 months for 1 year and then annually. Select the lab tests required for Atypical antipsychotic meds: thyroid function liver function tests (LFTs) renal function hemoglobin A1C (HbA1C) complete blood count (CBC) serum drug level hemoglobin A1C (HbA1C) complete blood count (CBC) Rationale: Atypical antipsychotics can cause increased blood glucose and an increased risk of developing DM II. Measure HbA1C every 3 months for 1 year and then annually. Certain medications, such as Clozapine, may cause blood dyscrasias and CBC should be monitored closely. Bipolar disorder medications -Lithium -lamotrigine (Lamictal) -valproic acid (Depakene) -Second generation antipsychotics -carbemazepine (Tegretol) Bipolar disorder medications: Lithium -Lithium • Action: alters cation transport in the nerve & muscle • Indication: euphoric mania, rapid cycling, maintenance therapy • Adverse Effects: ➣GI effects, tremor, polyuria • Monitor plasma levels • Use to protect against suicide Bipolar disorder medications: lamotrigine (Lamictal) -lamotrigine (Lamictal) • Action: affects sodium channel ion transport & enhances the activity of y-aminobutyric acid (GABA) • Indication: maintenance therapy, monotherapy • Adverse Effects: ➣benign rash (risk for rare Stevens-Johnson Syndrome rash & multi-organ failure), GI effects, dizziness, h/a • equal in efficacy to lithium • Take at bedtime due to sedation side effect Bipolar disorder medications: valproic acid (Depakene) -valproic acid (Depakene) • Action: affects ion transport and enhances the activity of y-aminobutyric acid (GABA) • Indication: acute mania, mixed mood, comorbid substance use, multiple prior episodes • Adverse Effects: ➣GI effects, weight gain • equal to lithium • Monitor plasma levels • If using with lamotrigine decrease valporate levels by 50% Bipolar disorder medications: Second generation antipsychotics -Second generation antipsychotics • Action: DA, NE, and 5-HT receptor antagonists • Indication: acute bipolar depression, acute manic or mixed episodes, bipolar maintenance/adjunct • Adverse Effects: ➣weight gain, sedation, GI effects • Monitor for extrapyramidal effects • XR form may improve adherence • injection may improve adherence Bipolar disorder medications: carbemazepine (Tegretol) -carbemazepine (Tegretol) • Action: glutamate voltage gated sodium & calcium channel blocker (Glu-CB • Indication: acute mania, mixed mood • Adverse Effects: ➣GI effects, sedation, hyponatremia, neutropenia, rash (Stevens-Johnson Syndrome) • Monitor plasma levels • Consider genotyping clients with Asian ancestry ➣HLA-B 2501 allele increases risk of Steven-Johnson Syndrome Maternal mental health disorders (MMHDs) -Nearly 20% of women experience depression during the perinatal period (affect 1 in 5 women) -can occur anytime in the two years between conception and the first 12 months after childbirth • symptoms before pregnancy, during, or in first postpartum year -Maternal suicide • leading cause of death in postpartum period • among leading causes of death in pregnancy -prevalence of perinatal maternal deaths r/t substance abuse is almost as common as suicide -Untreated MMHDs can have significant adverse effects on fetal, neonatal, childhood, & adolescent outcomes • attachment disorders, cognitive & developmental disorders, relationship strain consequences of untreated MMHDs: Impact on the Mother • Have poor nutrition • Use substances such as alcohol, tobacco, or drugs • Experience physical, emotional, or sexual abuse • Be less responsive to baby's cues • Have fewer positive interactions with baby • Experience breastfeeding challenges • Question their competence as mothers consequences of untreated MMHDs: Impact on the Child • Low birth weight or small head size • Pre-term birth • Longer stay in the NICU • Excessive crying • Impaired parent-child interactions • Social-emotional, cognitive, language, motor, & adaptive behavior development • Untreated mental health issues in the home may result in an Adverse Childhood Experience, which can impact the long-term health of the child. terms used to refer to the conditions women experience during pregnancy and the first postpartum year: -postpartum depression (PPD) -perinatal (or antenatal, prenatal, or postpartum) depression & anxiety -perinatal mood disorders (PMDs) or perinatal mood & anxiety disorders (PMADs) -maternal mental health disorders Barriers to Maternal Mental Health Care -inconsistencies in terminology can lead to mistreatment in maternity care -classification of maternal mental health disorders in the (DSM-5-TR) • depressive disorder specifier "with peripartum onset" timeframe for using the specifier remains confined to the first four weeks after birth -unrealistic expectations -difficulties bonding with the infant or child -complicated relationships with birthparents in open adoptions -underestimation of the impact that adoption would have on parents' and families' lives -question their legitimacy as a parent MMHDs: Bipolar Disorder -DSM-5-TR includes a specifier for bipolar disorder with peripartum onset • symptoms that begin during pregnancy or in the first four weeks following childbirth -childbirth can trigger hypomanic episodes • often early in the postpartum period • may have severe depressive episode several weeks later -Early detection of signs of hypomania is necessary to reduce suicide & infanticide risk MMHDs: Anxiety Disorder -Generalized anxiety disorder • difficult to distinguish from symptoms experienced by new parents -Symptoms: irritability, difficulty sleeping, difficulty concentrating, easy fatiguability -Themes of worry: • pregnancy and delivery complications • infant well-being • maternal or partner illness -Risk factors: prior hx of ax MMHDs: Psychosis -DSM-5-TR: "brief psychotic disorder with peripartum onset" when symptoms present suddenly during pregnancy or within the first 4 weeks after birth & last at least one day but no more than one month -preexisting bipolar disorder have highest risk -Loss of sleep is common precipitating factor -presents with at least 1 of the following symptoms: • delusions • hallucinations • disorganized speech • grossly disorganized or catatonic behavior -Suicide and infanticide are primary concerns -Hallucinations or delusions r/t the infant are common -considered a psychiatric emergency & requires immediate hospitalization and tx __________________ is considered a psychiatric emergency and requires immediate hospitalization and treatment Perinatal psychosis MMHDs: OCD -Pregnancy creates risk for onset or exacerbation of OCD -peripartum period, approximately 1.5-2x more likely to experience OCD compared to general pop. -47% of women with OCD experience first onset during peripartum period -Common obsessions: • fears of contaminating the baby • need for exactness • thoughts of aggression towards infant ➣fear being left alone with infant, may distance self from infant to avoid acting on the thoughts • fears of infant death -common compulsions: • repetitive handwashing • checking the infant MMHDs: PTSD -1-5% experience PTSD during the perinatal period -Risk factors: • previous trauma • hx of sexual abuse • complications with past pregnancies • traumatic births or labor experiences • instrument-assisted vaginal births or cesarean sections • peripartum depression • previous mental illness maternal mental health disorders: Screening -recommendations from the American College of Obstetricians and Gynecologists (ACOG) • screening at least once during the perinatal period using a validated instrument • increasing the frequency of visits when symptoms are identified • referring clients for appropriate pharmacotherapy & psychotherapy treatments -American Academy of Pediatrics (AAP) recommends: • incorporating the Edinburgh Postnatal Depression Scale (EPDS) into infants' 1, 2, 4, and 6- month well check visits using a cutoff score of 10 as an indicator that maternal depression may be present Edinburgh Postnatal Depression Scale (EPDS) to screen for maternal mental health disorders -questionnaire to identify women who may have postpartum depression -A score of more than 10 suggests minor or major depression may be present • Further evaluation is recommended https://perinatology.com/calculators/Edinburgh%20Depression%20Scale.htm Shawnta is a 29-year-old who delivered her first child one month ago. She has been seeing a psychiatric mental health nurse practitioner for therapy for the past two years to work on post-traumatic stress disorder following a sexual assault. She has no other psychiatric or physical health history and no family history of mental illness. Shawnta presents for a telehealth therapy visit and notes that over the past few days, she has felt more "down" than usual. Her partner returned to work a we plan to repeat the screening in two weeks at Shawnta's next therapy appointment Rationale: Mothers who score over 13 on the EPDS are likely suffering from depressive illness; however, the EPDS only indicates how the client felt during the previous week. Therefore, a follow-up assessment in two weeks is indicated. At Shawnta's next appointment two weeks later, she endorses increased feelings of sadness and worry, mostly surrounding the baby. Her repeat EPDS screening score is 14. Which of the following management strategies is the most appropriate next course of action for Shawnta? plan to repeat the screening in two weeks at Shawnta's next therapy appointment request that Shawnta schedule an in-person visit as soon as possible request a joint therapy session with Shawnta's partner discuss antid discuss antidepressant medications Rationale: Shawnta's current EPDS score of 14 indicates likely depressive disorder, which requires the PMHNP to discuss treatment options with her, which may include antidepressant medications. treating MMHDs: Perinatal Depression -SSRIs: first-line pharmacologic once bipolar II disorder ruled out -tricyclic antidepressants -omega-3 fatty acids may reduce depressive symptoms -brexanolone: • new tx for postpartum depression • IV infusion over 60 hours at certified healthcare facility • must be enrolled in the Risk Evaluation & Mitigation Strategy Program -Nonpharmacologic: • CBT • interpersonal therapy • electroconvulsive therapy for severe treating MMHDs: Perinatal Bipolar Disorder -Pharmacologic: • lithium • lamotrigine -Nonpharmacologic: • CBT • interpersonal therapy • behavioral therapy • social rhythm therapy treating MMHDs: Perinatal Anxiety lurasidone 20 mg tablet Disp: 30 Sig: 1 tab po daily with food at dinner Refills: 0 The client will return for follow up and medication efficacy prior to 30 days. Rationale: Lurasidone is a 5HT2A/D2 antagonist approved for use in schizophrenia and bipolar depression. This compound exhibits high affinity for both 5HT7 receptors and 5HT2A receptors, moderate affinity for 5HT1A and α2 receptors, yet minimal affinity for H1 histamine and M1 cholinergic receptors, which is a good choice for a new mother. There is also a low risk of weight gain or metabolic dysfunction. This medication was approved for pregnancy and postpartum use. Any medication that is prescribed while nursing requires a risk benefit discussion. A review of pediatric medical records have not shown adverse outcomes in breastfed infants, however the data is limited. Maternal Mental Health, Epigenetics, and Child Health: Lifespan Considerations -Maternal depression & anxiety can impact: • fetal development in utero • increase risk for preterm birth & low birth weight • lead to an insecure attachment between mother & infant • suboptimal breastfeeding practices • long-term effects: ➣decreased social-emotional, cognitive, language, motor, & adaptive behavior developmental outcomes -PTSD following trauma exposure in childbearing people • lasting detrimental impact on child health How a caregiver's trauma can impact a child's development: Early development -Mother releases cortisol • Baby absorbs cortisol through placenta ➣Can impact baby's: HPA axis, CNS, Limbic system, ANS -Caregiver struggles to regulate -Attachment relationship strained • Can impact child's: ➣Development of a core sense of self ➣Ability to integrate experiences ➣Epigenetic expressions How a caregiver's trauma can impact a child's development: Adulthood -person who had a caregiver with untreated trauma may: • Be more prone to PTSD after trauma • Struggle to repair after conflict • Struggle with relationships • Unintentionally bring out negative behaviors in others • Be emotionally detached • Be more prone to dissociate Stigma of Maternal Mental Health Disorders -may impact the individual's sense of safety regarding sharing their negative or challenging experiences • may fear revealing symptoms to others out of shame, guilt, or fear that their infant may be taken away from them ___________ and ___________ have been demonstrated to have the lowest serum concentrations among infants exposed to medication during breastfeeding Bupropion and Sertraline Pediatric Anxiety & Obsessive-Compulsive Disorder (OCD) -Separation anxiety -Social anxiety -OCD -Body dysmorphic disorder Anxiety -Increased brain activity in the amygdala & prefrontal cortex -PET scans have also shown reduced serotonin binding in patients with anxiety -GAD • persistent, uncontrollable worrying that causes emotional distress, symptoms on most days, for a period of at least 6 months -Symptoms: • worrying, restlessness, irritability, muscle tension, fatigue, sleep disturbances Risk factors for developing anxiety -genetic predisposition (family history of anxiety) -being female -recent life stressors -chronic physical illness -lack of support during childhood Medications for anxiety: GAD -SSRIs -SNRIs -buspirone -Drug Therapy at least 12 months Medications for anxiety: Panic Disorder -paroxetine -sertraline -fluoxetine -Drug therapy 6-9 months Medications for anxiety: OCD -fluoxetine -fluvoxamine -sertraline -paroxetine -clomipramine (TCA) -Drug therapy for at least 1 year Medications for anxiety: Social Anxiety Disorder -sertraline -paroxetine -Drug therapy takes 4 weeks to see effects Medications for anxiety: PTSD -paroxetine -sertraline Depression -Decreased brain activity in the prefrontal cortex -symptoms that last >2 weeks -Symptoms: • depressed or irritable mood, diminished interest in activities, significant weight or appetite changes, fatigue, feelings of worthlessness, sleep disturbances, diminished ability to concentrate -can be influenced by genetic & environmental factors, stressful life events • giving birth or experiencing emotional trauma -linked to neurotransmitter imbalances MDD -primary feature of MDD is the occurrence of at least 1 episode of major depression lasting at least 2 weeks -must experience 5 or more of the following symptoms in 2 weeks to be diagnosed with a major depressive episode: • feeling low most of the day for most days • decreased interest in activities • substantial weight loss, significant change in appetite • fidgeting, random movement (i.e. pacing) • decreased energy • sense of guilt or worthlessness • lack of focus or ability to make decisions • repeated thoughts of death and suicide Medications for depression -SSRIs -SNRIs -NDRIs -TCAs -MAOIs Selective Serotonin Reuptake Inhibitors (SSRIs) -Action: • inhibits 5-HT (serotonin) reuptake -Ex: • citalopram • Adverse Effects: ➣GI effects, sedation, hyponatremia, neutopenia, rash (Stevens-Johnson Syndrome) • Monitor plasma levels • Consider genotyping clients with Asian ancestry ➣HLA-B 2501 allele increases risk of Steven-Johnson Syndrome pediatric anxiety disorders -among the most diagnosed mental health disorders • 9.4% of U.S. children & youth (5.8 billion) -can result in: • academic & social impairment • persist into adulthood • comorbid mental health problems, depression most common -Anxiety Disorders by age • 1.3% of children aged 3-5 years • 6.6% of children aged 6-11 years • 10.5% of children aged 12-17 years prevalence of OCD -between 1%-4% • 80% show symptoms by age 18 common symptoms of anxiety in children -Trouble concentrating -Fatigue -Irritability -Muscle tension -Frequent urination -Upset stomach -Trouble sleeping -Restlessness -Nightmares -Fidgeting -Poor performance at school clinical presentation of pediatric: GAD -excessive or unrealistic worry about everyday life events that are out of proportion to the impact of the events -only one physical or cognitive symptom is required for diagnosis • whereas three symptoms are required for adult diagnosis clinical presentation of pediatric: Separation Anxiety Disorder -Separation anxiety typically peaks between 10-18 months and ends by about 3 years (developmentally appropriate in children under 3) -disorder occurs when a child experiences intense or prolonged worry or fear about being separated from family members or other individuals with whom the child is close • may be triggered by stress that leads to separation from a loved • diagnosed when symptoms are excessive for the developmental age and interfere with daily functioning risk factors for separation anxiety -recent loss of a family member -exposure to disturbing subject matter -female sex -positive family history -shy personality -extended parental conflict or absences -relocation due to moving clinical presentation of pediatric: Social Anxiety Disorder or Social Phobia -intense fear of social situations, including performing in front of others • scrutiny, embarrassment, or humiliation are possible -clinically significant distress and interferes with daily activities -Physical symptoms: • blushing, stammering, nausea, difficulty speaking, racing heart -may manifest with: • tantrums, crying, clinging, freezing up, withdrawing from social situations -Dx: symptoms consistently present in similar situations for 6 months+ & anxiety must occur in settings with peers, not just interactions with adults clinical presentation of pediatric: Selective Mutism (SM) -ind. unable to speak in certain social settings they find stressful • school or work -can communicate well in other settings • home or with family -usually starts between ages 2-4 -more common in females -commonly comorbid with social anxiety disorder -Dx: based on the client's medical, developmental, & family history • Collaboration with speech-language pathologist is recommended -Tx: psychological treatment & referral for speech & language therapy screening for anxiety in children -commonly used tool: Screen for Child Anxiety Related Disorders (SCARED) tool Child Version • screen for several types of anxiety disorders ➣generalized anxiety ➣panic disorder ➣separation anxiety ➣social anxiety -total score of 25 or more points indicates a potential anxiety disorder • higher scores, more specific results Treatment for Pediatric Anxiety Disorders -psychotherapy • Cognitive-behavioral therapy (CBT) most common -pharmacologic • First-line is SSRIs • Benzodiazepines used sometimes for short-term tx ➣especially for certain phobias, fear of dental/medical tx Eliana Swan (DOB: 6/18/20XX)is a 10-year-old who has a history of dental phobia after a traumatic experience during a root canal. She must have a tooth extraction and her mother is concerned that Eliana will not be able to tolerate the procedure without "something to help her relax." Eliana weighs 71 pounds. In the activity below, write an appropriate prescription for Eliana. Rx: lorazepam 1.0 mg tablet PO Disp: 1.5 tablets Sig: Take 45 to 90 minutes before the procedure Refills: 0 Rationale: A benzodiazepine, such as lorazepam, may be prescribed for children with specific phobias r/t dental or medical treatments. An appropriate dose of lorazepam is 0.05 mg/kg PO as a single dose 45 to 90 minutes before the procedure. Obsessive-Compulsive Disorder -Onset is gradual • 25% cases emerge between 8-12 years -Symptoms: • persistent, intrusive thoughts (obsessions) • repetitive behaviors performed to decrease obsession-related anxiety (compulsions) -diagnostic criteria: obsessions & compulsions time-consuming (>1 hour per day) & disrupt normal routines, functioning, or relationships. -Common in children: washing, checking, ordering, fear of catastrophe small subset of children with OCD, the diagnosis is associated with ________________ streptococcal infections -acronym PANDAS • pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections ➣used to identify this subset ➣lab test called the Cunningham Panel to aid in identifying children with PANDAS ➣PANDAS is treated with antibiotics while OCD symptoms are treated with a combination of CBT & SSRIs Children with PANDAS and SSRIs: -Children with PANDAS may be particularly sensitive to side effects of SSRIs • important to begin treatment with low doses & increase slowly screen for OCD in children and adolescents -commonly used tool: Children's Yale-Brown Obsessive-Compulsive Scale (CY-BOCS) • children & adolescents aged 6-17 Tx of OCD in children and adolescents -First-line treatment for mild to moderate OCD is CBT • used alone or in combination with medication ➣SSRI or clomipramine -irritability, agitation, and impulsivity. • Generally, these symptoms are time-limited and can be managed with care and support. !!!!!!!!!!This SSRI has been associated with increased suicidal thinking & actions in children & adolescents & should not typically be used to treat depression in this population!!!!!!!!!!!!!!!!!!!! Paroxetine SSRI tx phases: -Acute phase: Aim is to achieve a significant reduction or disappearance of symptoms for 8-12 weeks. -Continuation phase: Aim is to consolidate treatment gains and prevent relapse for 6 to 12 months. -Maintenance phase: Aim is to prevent relapse by continuing treatment for those with recurrent, severe, or chronic depression. Initiating SSRI with child or adolescent *Start at low doses with dose increase or med change only after 4 weeks *Symptom severity should be assessed every 1-2 weeks after initiating medication along with continuous monitoring of suicidality Mood Disorders in Children & Adolescents: Bipolar Disorder (BPD) -Dx of children before puberty remains controversial -Common comorbidities: ADHD, anxiety disorders, oppositional defiant disorder, learning disorders, substance use -Clinical Presentation: more rapidly cycling moods & mixed episodes, symptoms of both mania and depression together Bipolar Disorder (BPD) Screening -Kiddie Schedule for Affective Disorders and Schizophrenia for School-Aged Children interview tool • validated tool for use in diagnosing BPD Treatment for pediatric BPD -typically includes a combination of medication and psychotherapy • mood stabilizers & antipsychotic medications ➣help tx symptoms/stabilize pt so they are able to participate in psychotherapy -Psychosocial interventions • education, skill-building, and lifestyle modifications -Motivational interviewing: promote medication adherence -Family-focused therapy: help youths at high risk for BPD increase the time between mood episodes through psychoeducation, communication, & problem-solving skills training -Interpersonal and Social Rhythm Therapy (IRPT): help clients manage life with a mood disorder by promoting regularity in daily routines Nic, a 15-year-old, was admitted to an inpatient adolescent psychiatric unit. He has been diagnosed with bipolar I disorder and has suicidal ideations. Match the scenario with the most appropriate initial medication: divalproex lithium lurasidone lithium Rationale: Lithium can reduce suicidality; clients who have suicidal ideations should be carefully monitored until therapeutic levels are reached. Toni, a 17-year-old, has complaints of irritability, racing thoughts, high energy, and low mood. Match the scenario with the most appropriate initial medication: divalproex lithium lurasidone divalproex Rationale: Divalproex is the preferred drug for adolescents with bipolar disorder with mixed features. Antoine, an 11-year-old, was diagnosed with bipolar depression. Match the scenario with the most appropriate initial medication: divalproex lithium lurasidone lurasidone Rationale: Lurasidone is an appropriate treatment for bipolar depression in adults and children over 10 years of age. Kenzie is a 10-year-old who was diagnosed with bipolar I disorder, acute manic episode. Since she has trouble swallowing pills, she was initially started on lithium immediate release solution 12 milliequivalents per liter (mEq) three times daily. She returns to the PMHNP's office one week after her initial diagnosis for follow-up and lab work. Kenzie's mother reports that although her mood seems less severe, she continues to have high levels of irritability, loss of appetite, insomnia, and "mood swings". Kenzie's lithium level is 0.7 mEq/L. Which of the following is the most appropriate management strategy for Kenzie? increase lithium dosage to 16 mEq three times daily decrease lithium dosage to 12 mEq three times daily stop lithium and begin divalproex increase lithium dosage to 16 mEq three times daily Rationale: Kenzie's lithium level is subtherapeutic; therapeutic levels are between 0.8-1.2 mEq/L for clients experiencing acute mania. Since Kenzie is still experiencing symptoms, it is appropriate to increase her dose. The maximum dosage for immediate release solution in children 7 and older weighing greater than 30 kg is 48 mEq/day given in 2-3 divided doses. When should the PMHNP schedule a follow-up visit for Kenzie? one day five days one week two weeks five days Rationale: The time to efficacy for lithium is 3-5 days in children; a follow-up visit or phone call at 5 days will allow the PMHNP to reassess the efficacy of Kenzie's new dose. Mood Disorders in Children & Adolescents: Disruptive Mood Dysregulation Disorder (DMDD) -first appeared in the DSM-5 in 2013 -Clinical Presentation: • chronic, persistent irritability & anger • frequently experience problems at home, school, or with peers -DSM-5-TR criteria: • severe, recurrent (>3 times per week) outbursts of temper • mood between outbursts of temper is chronically irritable or angry most of the day, every day, and is observable to others • symptoms have been present >12 months with no more than 3 consecutive months without symptoms • symptoms are present in at least 2 of 3 settings (home, school, or with peers), severe degree in at least one setting • diagnosis cannot be made before age 6 or after age 18 years • onset begins before age 10 • behaviors cannot be attributed to another mental disorder -cannot coexist with dx of bipolar disorder, intermittent explosive disorder, or ODD • symptoms of both DMDD and ODD, the diagnosis of DMDD should be used Disruptive Mood Dysregulation Disorder (DMDD) Screening -The Kiddie Schedule for Affective Disorders and Schizophrenia for School-Aged Children (KSADS-PL) • validated for use in combination with the DMDD module Disruptive Mood Dysregulation Disorder (DMDD) Tx -psychotherapies and medication • CBT ➣used to teach children & adolescents to manage thoughts & feelings that contribute to depression or anxious feelings actions of others • Somatic: delusions related to the body, including illness or the presence of foreign objects (e.g. Sometimes people believe there are objects in their bodies; for example they might think they are infested with insects.) • Grandeur: delusions related to beliefs of special abilities or powers • Control: delusions that actions and thoughts are controlled by others Thought Disorder: -impairment in the process of thinking & difficulty organizing thoughts in a logical pattern • incoherent speech • loose associations • meaningless words • perseveration Disorganized behavior: -disordered or impaired behavior or communication • childlike silliness • unpredictable agitation • inappropriate clothing for the weather • poor hygiene Erica is a 24-year-old with a newly diagnosed schizophreniform disorder. She is a current smoker. She does not use alcohol or other drugs. She has no medical history. Which of the following would be the least appropriate initial medication for Erica? aripiprazole lurasidone olanzapine quetiapine olanzapine Rationale: Olanzapine requires up to 30% increased dosage for clients who smoke concurrently. Initiating a medication that does not interact with smoking is preferable. Tony is a 56-year-old who has recently been diagnosed with schizophrenia. He takes amiodarone for a history of cardiac dysrhythmias. He does not use alcohol or other drugs. He is a nonsmoker. Which of the following is the most appropriate medication for Tony? aripiprazole lurasidone quetiapine risperidone risperidone Rationale: Amiodarone is a moderate CYP3A4 inhibitor. Risperidone does not interact with CYP3A4 inhibitors or inducers. Jenny is a 22-year-old who has been prescribed aripiprazole 15 mg/day for the past 8 months. She has gained approximately 30 lbs. during treatment. Jenny's psychiatric symptoms have been managed well on aripiprazole and she has no other adverse effects. What is the most appropriate initial intervention for Jenny? switch to a different antipsychotic medication prescribe metformin refer to a bariatric specialist prescribe metformin Rationale: Prescribing metformin as an adjunct treatment to assist with weight loss associated with antipsychotics is appropriate. Jenny is well-managed on the current dose of aripiprazole; switching to a different medication is not indicated at this time. Referral to a bariatric specialist may be indicated if the client continues to gain weight but is not indicated as the most appropriate initial intervention. Scott is a 33-year-old who is currently without housing. He has been unable to adhere to his prescribed oral medication regimen. The PMHNP recommends a long-acting intramuscular form of medication. Scott is willing to try but would like to receive the medication at the community clinic near the shelter where he is staying. Which medication option is the least appropriate for Scott at this time? aripiprazole monohydrate olanzapine paliperidone palmitate risperidone olanzapine Rationale: Olanzapine must be given in a registered health care facility with available emergency medical services. The client receiving olanzapine must be monitored for 3 hours post-injection. Autism Spectrum Disorder (ASD) -neurological and developmental disorder -impacts communication, relationships with others, learning, behavior -1-2% of population -all racial, ethnic, and socioeconomic groups -Males 4x more likely than females -Factors with increased risk: • having a sibling with ASD • having older parents • having certain genetic conditions: ➣Fragile X syndrome ➣Down syndrome • very low birth weight -spectrum disorder • wide variation in the types and severity of symptoms ➣symptoms typically appear in first 2 years of life DSM-5-TR criteria for ASD -persistent deficits in communication and social interaction across multiple contexts and restrictive, repetitive patterns of behavior, interests, or activities -Symptoms must appear early in development and can cause clinically significant impairment in functioning -severity is classified based on the level of support needed by the individual ASD Diagnosis and Screening -The American Academy of Pediatrics (AAP) recommends that all children be screened for ASD • Providers perform basic developmental screenings at children's 18-month and 24-month well- child visits • demonstrate developmental differences in behavior or functioning require additional evaluation, typically performed by a team of ASD specialists ➣child psychologist, speech-language pathologist, occupational therapist, developmental pediatrician, or neurologist -Dx based on clinical observations, observations in a natural setting, caregiver history, or self- reports ASD different developmental screening tools available -Screening tools: • Ages and Stages Questionnaires (ASQ) • Communication and Symbolic Behavior Scales (CSBS) • Parents' Evaluation of Developmental Status (PEDS) • Modified Checklist for Autism in Toddlers (MCHAT) • Screening Tool for Autism in Toddlers and Young Children (STAT) -Diagnostic tools • Autism Diagnosis Interview - Revised (ADI-R) • Autism Diagnostic Observation Schedule - Generic • Childhood Autism Rating Scale (CARS) • Gilliam Autism Rating Scale - Second Edition (GARS-2) Early signs of ASD include: -avoiding eye contact -showing little interest in peers or caretakers -limited language abilities -frustration with minor changes in routine -repetitive behaviors Quentin is a 4-year-old who presents with his parents for evaluation. Before the appointment, the psychiatric mental health nurse practitioner (PMHNP) read a report submitted to the office by Quentin's preschool teacher, who notes that he is easily distracted, often "fidgety", and has difficulty waiting his turn. He gets frustrated when the guanfacine Rationale: Alpha-agonist medications, such as guanfacine or clonidine, may be used for clients with ASD who have hyperactivity, impulsive behaviors, and sleep problems. Ariana, a 9-year-old with ASD, has a history of aggressive behaviors, tantrums, and motor tics. match the scenario with the appropriate med: guanfacine clomipramine aripiprazole methylphenidate aripiprazole Rationale: Second-generation antipsychotic medications may be used for clients with ASD who have aggressive behaviors, tantrums, sleep disorders, or motor tics. Seth, a 15-year-old with ASD, has a history of stereotypies including toe-walking and arm flapping. match the scenario with the appropriate med: guanfacine clomipramine aripiprazole methylphenidate clomipramine Rationale: Tricyclic antidepressant medications may be used for clients with ASD who have repetitive behaviors and aggression. Tyrek, an 11-year-old with ASD, has a history of hyperactivity and impulsive behaviors at school. match the scenario with the appropriate med: guanfacine clomipramine aripiprazole methylphenidate methylphenidate Rationale: Stimulant medications may be used for clients with ASD who have hyperactivity, short attention spans, and impulsive behaviors. Rett Syndrome -rare neurodevelopmental disorder • typically caused by mutation in methyl CpG binding protein 2 (MECP2) -affecting one in every 10,000-15,000 live female births worldwide • Boys born with the defect typically have severe problems when they are born & die shortly after birth -spontaneously and is not inherited -Characterized by: • normal growth and development early in life followed by impaired growth and development later in life • children may exhibit behaviors similar to ASD • mental & physical symptoms, loss of the purposeful use of the hands & ability to speak • Apraxia why boys are affected worse by rett syndrome -MECP2 gene is carried on the X chromosome. -In girls, only one X chromosome is active in any given cell, so some cells express the mutation while others do not. -severity of the symptoms r/t the % of cells that express an abnormal copy of the MECP2 gene. -Because boys only have one X chromosome, there is no compensation for the gene defect Rett Syndrome Diagnosis and Screening -Children with symptoms of Rett syndrome • refer to neurologist or neurodevelopmental pediatrician ➣further evaluation of physical & neurological status -clinical geneticist can help confirm the diagnosis Rett Syndrome treatment -No cure -treatment can help: • slow the loss of abilities • preserve function • improve communication & socialization -Therapy • Physical, occupational, & speech ➣assist with function, safety, communication -Orthotics, prosthetics, braces, specialized seating, mobility equipment • encourage independence, manage bone & joint deformities -Meds • control seizures, assist with breathing problems & motor difficulties. Treating Rett Syndrome continued: -Anti-seizure medications -Spinal fusion surgery (if scoliosis develops) -Custom seating equipment -Augmentative communication -Occupational therapy -Physical therapy -Leg braces Tourette syndrome (TS) -chronic neurodevelopmental disorder -often referred to as a tic disorder -characterized by: • abrupt, quick, recurrent, nonrhythmic motor movements or phonic vocalizations -onset typically between 5-7 years • often increases in frequency & severity between 8-12 years -0.52% of children 4-18 have TS -Males more common than females -often comorbid with other psychiatric conditions: • ADHD, OCD, learning difficulties, depression predominant symptoms of TS Tics -often begin as motor tics in the neck & head area -Tics often intensify with stress or excitement -improve with focused or calming activities -often decrease during late adolescence & early adulthood & may disappear in some individuals Tourette syndrome (TS) Diagnosis DSM-5-TR four diagnostic criteria are required for TS including: -presence of multiple motor tics & one or more vocal tics, which may not occur concurrently -tics may wax & wane in frequency but have persisted for more than 1 year since the first tic onset -tic onset is before 18 years of age -not caused by the use of a substance or other medical conditions Tourette syndrome (TS) Screening The Yale Global Tic Severity Scale (YGTSS) -valid instrument used to assess tic severity and overall impairment of TS on the client's quality of life. John is a 7-year-old who often clears his throat while playing. match the clinical scenario with the appropriate tic: Simple motor tics Complex vocal tics: Coprolalia Complex motor tics Simple vocal tics Complex vocal tics: Echolalia Complex motor tics: Copropraxia Simple vocal tics Rationale: Simple vocal tics are caused by contraction of the diaphragm or oropharynx muscles and include frequent throat clearing, sniffs, chirps, barks, or grunting. Clarence is an 8-year-old who blinks his eyes or makes facial grimaces when doing his homework. match the clinical scenario with the appropriate tic: Simple motor tics Complex vocal tics: Coprolalia • many children do not report due to fear the voices will harm them -negative symptoms • often misinterpreted by parents as laziness, lack of motivation, depression -Cognitive decline is common: • verbal memory, attention, concentration -may cause developmental delays Ketanji is a 7-year-old who endorses hearing her grandmother speaking to her regularly. She witnessed her grandmother die from a heart attack in the home. match the clinical scenario with the most appropriate diagnosis: Bipolar I disorder Substance-induced psychosis COS PTSD Anxiety Autism spectrum disorder (ASD) PTSD Rationale: Children who experience trauma may have flashbacks described as auditory hallucinations. Stephen is an 8-year-old who has difficulty with social interactions. He frequently appears withdrawn, and his speech sometimes seems disorganized. match the clinical scenario with the most appropriate diagnosis: Bipolar I disorder Substance-induced psychosis COS PTSD Anxiety Autism spectrum disorder (ASD) Autism spectrum disorder (ASD) Rationale: Social impairment, withdrawal, and stereotyped use of language are common symptoms of ASD that may be confused with COS. Sonia is a 12-year-old who presents with tangential speech and psychomotor agitation; she states that she will be competing as a ski jumper in the upcoming Olympics and is sure to win the gold medal. match the clinical scenario with the most appropriate diagnosis: Bipolar I disorder Substance-induced psychosis COS PTSD Anxiety Autism spectrum disorder (ASD) Bipolar I disorder Rationale: Disorganized speech or thought processes, psychomotor agitation, and delusional thinking are common symptoms of BPD that may be confused with COS. Elena is a 6-year-old who describes visual hallucinations of a tall, thin, shadowy man in her room. match the clinical scenario with the most appropriate diagnosis: Bipolar I disorder Substance-induced psychosis COS PTSD Anxiety Autism spectrum disorder (ASD) Anxiety Rationale: Younger children with symptoms of anxiety may report auditory or visual hallucinations as a manifestation of the anxiety. John is a 12-year-old who has become increasingly socially isolated over the past year. His parents' state he is completely unmotivated and often seems "in his head", and his sister notes that she often hears him having "frightening" conversations with himself in his room at night; he denies hallucinations. match the clinical scenario with the most appropriate diagnosis: Bipolar I disorder Substance-induced psychosis COS PTSD Anxiety Autism spectrum disorder (ASD) COS Rationale: Social isolation and withdrawal are common prodromal symptoms in children who have COS. Children often deny hallucinations due to fears of harm or of being considered mentally ill. Ruth is a 14-year-old who spent the night at a friend's house. Since she returned home, she has locked herself in her bedroom. When her mother knocked on her door to check on her, she stated she can't stop floating and she is afraid she will float away if the door opens. She admitted to her mother that she and her friend had experimented with marijuana and molly the previous night. match the clinical scenario with the most appropriate diagnosis: Bipolar I disorder Substance-induced psychosis COS PTSD Anxiety Autism spectrum disorder (ASD) Substance-induced psychosis Rationale: Substances that may induce psychosis in teens include hallucinogens, ecstasy, methamphetamines, marijuana, and alcohol. Polysubstance use increases the risk of psychotic episodes. Childhood-Onset Schizophrenia (COS) Treatment -antipsychotic medication is First-line treatment -Treatment is often lifelong -Second-generation antipsychotics have high risk of metabolic side effects, monitor: • weight • blood pressure • fasting glucose • lipid levels -First-generation antipsychotics, higher cumulative risk of tardive dyskinesia • reserve for pts who don't respond to second-generation antipsychotics -Augment medications with individual & family therapy • assist with reduction of symptoms • improved communication & conflict resolution • development of coping strategies for client & family Symptom-Triggered Therapy Step 1: Administer CIWA-Ar -Administer every 4-8 hours until the score is lower than 8-10 for 24 hours. Step 2: Symptom-Triggered Regimen -If the CIWA-Ar score is 8 or higher, administer benzodiazepine: PO lorazepam (Ativan), diazepam (Valium), or chlordiazepoxide (Librium) for symptom-triggered therapy. -Reassess CIWA-Ar every hour.