NR 606 Midterm Questions and Answers

NR 606 Midterm Questions and Answers 2. What are the key components of informed consent in pediatric mental health? Capacity & assent: Children should give age-appropriate assent; adolescents may give informed consent in some states. Children should be included in discussions about medication and tx. Understanding: Present purpose, benefits, risks, alternatives, and limits (e.g., mandatory reporting) in developmentally appropriate language. Voluntariness: No coercion. Documentation: Consent and assent should be recorded formally. 3. What prescribing considerations are unique to children/adolescents? Start with low, weight-based doses and uptitrate carefully. Consider developmental PK/PD factors (liver/kidney immaturity, different body water/fat ratios). Watch for off-label use due to limited pediatric trials. Monitor side effects rigorously (e.g., growth suppression, metabolic changes). Remember children have a faster metabolism than adults and may require larger doses of medication per unit of body weight. Around puberty pharmacokinetic properties reach adult parameters.After puberty dosing may need to be decreased What triggers mandatory reporting when treating minors? Providers must report suspected child abuse, neglect, or intent to harm self/others. Familiarity with your state's statutes and clear documentation are essential. 5. What considerations apply to psychotropic use during pregnancy? Risk–benefit analysis is essential: untreated maternal illness may pose higher risks. Medication selection: SSRIs are generally first-line; some mood stabilizers and antipsychotics may also be acceptable. Physical changes: Increased volume of distribution and altered metabolism require dosing adjustments Fetal risks: Consider teratogenicity (e.g., certain mood stabilizers), withdrawal syndromes, or neonatal adaptation syndromes. 6. What are the concerns when prescribing to breastfeeding mothers? Assess drug excretion into breast milk—prefer medications with low infant exposure and favorable safety profiles (e.g., many SSRIs). Balance maternal benefit and infant safety. Monitor baby for sedation, feeding difficulties, or irritability. What are the main substance risks during pregnancy?(highest age group is 18-29) Alcohol: Fetal Alcohol Spectrum Disorders—neurodevelopmental and physical impacts. Exposure within the first trimester has the most significant alcohol related birth outcomes Causes: miscarriage, stillbirth, congenital anomalies, low birth wt, preterm delivery. Life long effects include: fetal alcohol spectrum disorder, neurodevelopmental and CNS deficits, speech and language challenges, cognitive and behavioral deficits, impaired executive functioning, psychosocial difficulties in adulthood Tobacco: during pregnancy causes: Ectopic pregnancy Placental abruption Placenta previa Fatal mortality Stillbirth Smoking related effects on neonates SIDS Birth malformations i.e oral clefts & neural tube defects Infants Asthma Cognitive impairment Lower respiratory illness ADHD CNS tumors Cannabis: Cognitive and behavioral concerns, emerging but inconclusive. Causes: preterm labor, low birth wt, adverse effects on fetal and adolescent brain growth, executive functioning skills, behavioral problems and academic achievement Opioids: Neonatal abstinence syndrome post-birth, increased risk of toxemia, low birth wt, respiratory complications, third trimester bleeding and mortality, SIDS Eclampsia, heart attack, HF, sepsis Cocaine causes Premature rupture of membranes, placental abruption, preterm birth, low birth wt,lower short term memory, delinquent behavior, earlier age of sexual activity & substance use 8. What ethical and legal issues arise with perinatal substance use? Reporting vs. treatment: Providers may fear legal reporting, deterring care. Criminalization risk: Some states prosecute prenatal substance use under child endangerment laws. Balance: Provide nonjudgmental, accessible treatment and clarify reporting regulations. How does stigma affect perinatal substance use? It can bar access to care and perpetuate disparities in tx services and outcomes Public stigma: Leads to shame and social isolation. Public stigma encompasses the attitudes, beliefs, and behaviors of groups or individuals which form a stereotype that creates an emotional reaction or prejudice and results in discrimination. A stereotypic belief that individuals choose to use alcohol or other drugs and blame them for their substance use disorder is an example of public stigma. Healthcare providers who have a conscious or unconscious bias against clients who use substances in the perinatal period may not provide appropriate care and treatment Self-stigma: Self-stigma refers to the shame individuals internalize about negative stereotypes. For individuals affected by SUDs, self-stigma may lead to feelings of being flawed or unworthy of love or connection. It may also prevent them from seeking help. Structural barriers: Structural stigma, or institutional stigma, includes policies, regulations, or laws that intentionally or unintentionally lead to discrimination. Structural stigma can limit access to resources and other opportunities, thereby impacting the well-being of the stigmatized group. A program policy that prohibits individuals from using specific forms of prescribed medication for addiction (MAT i.e methadone) treatment is an example of structural stigma. 10. How should providers screen for substance use during pregnancy? Use validated tools (e.g., 4Ps, CRAFFT, ASSIST). Apply routine screening for all patients. Screen continuously throughout prenatal care, recognizing dynamic usage. 11. What are effective treatment options for perinatal SUD? Behavioral: Motivational Interviewing, CBT, contingency management. Medication-assisted treatment (MAT): Methadone or buprenorphine for opioid use disorder. Integrated care: Combine prenatal, SUD, and mental health support alongside case management and peer support. A. Barriers to mental health care: Children/adolescents: Limited provider availability, insurance issues, transportation, stigma therefore many drop out, and misunderstanding of mental illness, scheduling conflicts, high staff turn over. Perinatal populations: Fear of legal consequences, limited maternity-SUD integration, childcare logistics, stigma. B. Social determinants affecting access: Income, insurance, transportation, neighborhood safety, and linguistic/cultural barriers impact service uptake, especially in youth. C. Developmentally appropriate teaching: Use simple language, visual aids, active learning (e.g., games), and involve parents/families. Ensure materials match the child's cognitive and emotional development. D. Racial and ethnic barriers: Distrust in healthcare systems, cultural stigma, lack of culturally tailored care, language limitations. The result: delayed help-seeking and poorer outcomes. E. Types of stigma: Structural: Institutional policies that reduce in states criminalizing opioid use during pregnancy are less likely to receive an accurate diagnosis and effective treatment; furthermore, criminalization strips these individuals of their ability to engage autonomously with their provider and impedes their ability to achieve recovery. Fear of legal repercussions and the involvement of children's services may lead women to avoid reporting substance use Public: Community stereotypes and prejudice. Self: Internalized shame that deters help-seeking. Intervention: Stigma focused on treatments or providers, affecting treatment engagement. F. Parental access to records: Typically, parents have the right to access their child's health records—but adolescence may shift this depending on privacy laws for sensitive services (e.g., reproductive or sexual health). G. Ethical/legal informed consent principles: Include autonomy, be I. Developmental Pharmacokinetics/pharmacodynamics in kids: Higher metabolic rates immature organs altered volumes of distribution—all affect how drugs act and are processed. Pediatric dosing principles: Use weight-based or body-surface-area dosing. Confirm dosing with reliable references. Monitor therapeutic effect and side effects. Double-check calculations (e.g., with a second clinician or pharmacy). What distinguishes "baby blues" from postpartum depression? Baby blues arise ~2–3 days after birth, peak around day 5, and resolve by day 14. Symptoms include mood swings, tearfulness, irritability, and fatigue. Additional sx include decreased appetite, difficulty sleeping, worrying. It does not impair maternal function Causes: drastic hormonal changes, fatigue after giving birth and breastfeeding, lack of support, transitioning to being a mother Postpartum depressionbegins within 4 weeks and lasts at least 2 weeks, with more severe symptoms: persistent sadness, guilt, hopelessness, impaired concentration, and possibly suicidal thoughts. 2. What are risk factors for maternal mental health disorders? History of mental illness (especially depression/anxiety), poor social support, history of trauma/survivor of abuse, unplanned pregnancy, pregnancy complications, economic stress, and sleep deprivation. . What are SSRI withdrawal symptoms in newborns? Newborns exposed to SSRIs in utero may experience irritability, feeding or sleep issues, tremors, hypoglycemia, respiratory distress, and jitteriness. These symptoms generally last a few days to a few weeks. What are diagnostic criteria for anxiety and depression in pregnancy/postpartum? Major depressive episode: ≥5 symptoms for ≥2 weeks (e.g., depressed mood, anhedonia, sleep/appetite changes, fatigue, guilt, concentration issues, suicidal thoughts). Anxiety disorders: Excessive worry, restlessness, fatigue, irritability, muscle tension for ≥6 months (Generalized Anxiety Disorder). Other disorders (e.g. OCD, PTSD) follow DSM‑5. What are key clinical signs and risk factors for postpartum PTSD? Clinical signs may include flashbacks, avoidance, hypervigilance, and guilt. Risk factors include traumatic delivery, prior trauma or PTSD, lack of support, and serious obstetric or neonatal complications. What treatments are recommended for severe postpartum depression? SSRIs (e.g., sertraline or paroxetine), psychotherapy (CBT, Interpersonal Therapy), and if severe: residential treatment, ECT, or neurostimulation (e.g., TMS) based on specialist guidance. 7. How are tobacco use and cannabis addressed in pregnancy? Tobacco: Use the “5 A’s” — Ask, Advise, Assess, Assist (via motivational interviewing), Arrange follow-up. Nicotine replacement may be considered if non-pharmacologic tools fail. Cannabis: Educate on risks (low birth weight, neurodevelopmental effects), and offer cessation support; safe pharmacotherapies are lacking. 8. Which mood stabilizers and antipsychotics are safer in pregnancy? Mood stabilizers: Lamotrigine preferred; lithium may be used with close monitoring (renal, thyroid, fetal heart). Antipsychotics:Haloperidol, risperidone, quetiapine are acceptable. Clozapine is lower-priority due to limited data. 9. What labs should be done for pregnant patients on antipsychotics? Baseline metabolic labs (glucose, lipids, liver and renal function), with regular follow-up every trimester or every 3–6 months depending on risk. What is the Edinburgh Postnatal Depression Scale (EPDS) A 10-item self-report tool scored 0–30; a score ≥10–13 suggests possible depression; ≥13 strongly indicates it. It assesses mood, anhedonia, anxiety, guilt, and suicidality. What's peripartum onset? A specifier for mood disorders (e.g., major depression) occurring during pregnancy or within 4 weeks postpartum. What are barriers to points of care (POC) in perinatal mental health? Barriers include lack of provider integration, fear of child-welfare involvement, stigma, insurance or financial limits, childcare issues, and transportation difficulties. 1. What's the process for discontinuing antidepressants in children? Taper slowly over weeks to months, depending on the dosage and duration of use, with monitoring for return of symptoms or withdrawal effects (e.g., irritability, sleep changes) What characterizes separation anxiety in children? Excessive fear or distress regarding separation from attachment figures, lasting ≥4 weeks in children -18 (DSM‑5), causing significant social, academic, or emotional impairment. Peaks between 10-18 months & ends by about 3 years old. What are DSM‑5 criteria for selective mutism? Consistent failure to speak in specific social settings (e.g., school), but speaking normally in others (e.g., at home), lasting at least 1 month and interfering with educational achievements or social communication. Starts to appear between ages 2-4 and is more common in females. It is often comorbid with social anxiety disorder How is pediatric OCD treated? First-line is a combination of SSRIs and CBT with exposure and response prevention (ERP). Clomipramine. Moderate to severe cases may benefit from antipsychotic augmentation or intensive therapy programs. (in some children OCD is a diagnosis associated with strep infections. PANDAS- pediatric autoimmune neuropsychiatric disorders is associated with OCD What are the criteria for bipolar disorder in children? Manic or hypomanic episodes with distinct mood changes (elevated or irritable), increased energy, and associated symptoms (e.g., distractibility, impulsivity) lasting ≥4 days for hypomania or ≥7 days for mania with marked impairment. What defines body dysmorphic disorder (BDD)? Preoccupation with perceived defects in appearance, causing repetitive behaviors. 1 or more perceived flaws. (e.g., mirror checking) and marked distress, despite normal appearance. What screening tools are used for child depression or anxiety? Anxiety: Screen for Child Anxiety Related Disorders (SCARED) Depression: PHQ‑9 modified for adolescents, Kiddie-SADS, Guidelines for Adolescent Depression in Primary Care (GLAD-PC), Yale‑Brown Obsessive Compulsive Scale for Adolescents (Y‑BOCS) Fluoxetine is the First line choice in adolescents What are PANS and PANDAS, and how are they assessed? PANS: Acute-onset OCD or eating restrictions PANDAS:OCD/tic disorders following strep infection Diagnosis involves observing rapid onset, tics or OCD, and anti-streptococcal testing (e.g., ASO titer). What's the difference between anxiety criteria in children vs adults? 1 physical or cognitive sx is required for a diagnosis in children whereas for an adult, 3 is required. For children, fears often occur in peer or social contexts; irritability often replaces reported worry; manifested in physical symptoms (e.g., stomachaches, headaches). DO NOT USE PAROXETINE IN CHILDREN. IT CAN INCREASE SUICIDAL THINKING . How do SSRIs affect bipolar disorder? SSRIs alone may trigger manic episodes in children with undiagnosed bipolar disorder. Always evaluate mood history before prescribing antidepressants Disruptive Mood Dysregulation Disorder Criteria: 3 outburst per week Dx cannot be made before 6 & after 10 DMDD cannot coexist with dx of BPD, Intermittent explosive disorder or oppositional defiant disorder. Stimulants can be used as treatment What are the core diagnostic features of Autism Spectrum Disorder (ASD)? Complex neurodevelopmental** Persistent deficits in social communication and interaction; restrictive, repetitive behaviors and interests. Onset usually in early childhood, impairing daily functioning. What are the ASD support-level qualifiers? In DSM-5: Level 3: Very substantial support Level 2: Substantial support Level 1: Requiring support May include intellectual impairment or catatonia specifiers. What are evidence-based ASD interventions? Applied behavior analysis therapy (ABA), Speech and occupational therapy, OT, parent training, dietary therapy, Pharmacologic treatment addresses comorbid symptoms (e.g., irritability with risperidone or aripiprazole). Serotonin agents, antipsychotics, beta blockers, alpha 2 agonist, mood stabilizer & stimulants. Use MUCH LOWER doses of stimulants Joaquin, a 12-year-old with ASD, has difficulty sleeping and displays impulsive behaviors at school. what medication would be appropriate & why Guanfacine because medications, such 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. what medication would be appopriate aripiprazole; 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. what medication would be appropriate clomipramine;clomipramine 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. what medication would be appropriate methylphenidate;Stimulant medications may be used for clients with ASD who have hyperactivity, short attention spans, and impulsive behaviors How are aggressive behaviors in ASD treated pharmacologically? Risperidone and aripiprazole are FDA‑approved for irritability. Off-label options include SSRIs, mood stabilizers, and stimulants as clinically indicated. What characterizes Tourette's Disorder/tic? Multiple motor AND ≥1 vocal tics present for at least 1 year; tic onset must be before age 18. Characterized by abrupt, quick, recurrent and nonrhythmic motor movements or phonic vocalization. Onset is 5-7 yrs. What is first-line treatment for Tourette's Behavioral: Comprehensive Behavioral Intervention for Tics (CBIT). If pharmacotherapy is needed: low-dose atypical antipsychotics (e.g., risperidone) or antidopaminergic agents (e.g., tetrabenazine). 7. What are prodromal symptoms of early-onset schizophrenia? Includes declining academic performance, social withdrawal, unusual perceptual experiences, odd beliefs, or flattened affect in adolescents. Auditory hallucinations are the most common sx in children though many do not report their hallucinations d/t fear the voices will harm them. What's the recommended length of antipsychotic treatment for a psychotic episode? At least *2 years* after full symptom remission. It helps the brain to rewire. For children/adolescents, ensure close monitoring during the maintenance period What is Rett syndrome? A genetic disorder caused by a(MECP2 mutations) seen only in girls, characterized by early developmental regression (loss of hand skills, speech), repetitive hand-wringing and deceleration of head growth. Characterized by normal growth & development early in life followed by growth and developments later in life. Apraxia is the most disabling aspect of Rett syndrome which interferes with all body movements including eye gaze & speech. Symptoms appear 6-18 months after a period of development but then regression occurs. Genetic testing is important. This is how it's diagnosed. Often coexist with anxiety. What are early signs and treatments for schizophrenia in youth? Signs: social isolation, odd speech, perceptual disturbances. Treatment: Early intervention with antipsychotics and therapy; sustained use of medication to reduce relapse risk.