NR606 / NR 606 Week 8 Final Exam | Latest 2026/2027 Edition | Diagnosis & Management in PMH II Practicum | Chamberlain | Practice Questions & Accurate Solutions

NR606 / NR 606 Week 8 Final Exam | Latest 2026/2027 Edition | Diagnosis & Management in PMH II Practicum | Chamberlain | Practice Questions & Accurate Solutions What ADHD symptoms are lack of attention to detail, careless mistakes, not listening, losing things diverting attention, forgetfulness Selective attention What ADHD symptoms are poor problem solving, trouble completing a task, disorganization, trouble sustaining mental effort Lack of sustained attention What ADHD symptoms are excessive talking, blurting things out, not waiting ones turn, interrupting Impulsivity What ADHD symptoms are fidgeting, leaving ones seat, running, climbing, trouble playing quietly Hyperactivity What ADHD symptom is common in childhood hyperactivity Effects of maturation ADHD- young kids may experience DD, bx less mature than peers Effects of maturation ADHD- teens poor academic performance, trouble driving, trouble in social situations, risky sexual bx, SUD Effects of maturation ADHD- Adult Issues with EF, attention, working memory, that cause issues with day to day fnx and performance at work and in relationships Dx criteria for ADHD How many s/s How long How many settings Pattern of 6 s/s that interfere with fnx/development, 6 months or longer Present in 2 or more settings How to combat anorexia with stimulant use Take medication with breakfast to decrease anorexia or associated weight loss When patients with ADHD have co morbid MH issues, what do you tx first ADHD (stimulants first line) Treating ADHD s/s first will give a clearer picture of the comorbidities Work up for starting stimulant ECG- if personal/first relative fmly hx Check bp/wgt/hgt What co morbidity should the PMHNP assess for before starting a stimulant BPD, CNS stimulant can cause psychotic or manic s/s in pt's with no prior hx or may exacerbate bx disturbances and thought d/o in pt's with pre-exisiting psychosis Stimulants can exacerbate what comorbid dx anxiety and SUD Increased irritability or insomnia can be tx with what low dose non stim Abrupt withdrawal from stimulants can cause what irritability and rebound s/s What to do with tx for ADHD if the pt is argumentative or oppositional Combo therapy with stim and non stim Recommendations for parent training in behavior management for ADHD as a first-line Intervention - What do the parents learn Recommended for child under 6 - Parents learn positive communication and reinforcement, structure, and discipline - Teaches kids to better control their own bx = improved fnx at school, home, and relationships What setting is ODD most common Home setting with peers or adults that the pt knows What is ODD proceeds Conduct disorder and ADHD, more common in boys anxiety and depression. Increased risk of SI Dx criteria for ODD -4 or more symptoms have occurred during an interaction with one or more individuals not including siblings within the last 6 months -Kids under 5 bx occur on most days for at least 6 months ODD s/s Angry/irritable mood: Loss of temper, easily annoyed, anger and resentment Argumentative/Defiant: Argues with authority figures, actively defiant or refusing to follow rules or requests from authority figure, deliberately annoys others, blames others for their mistakes/misbx Vindictiveness: spiteful or vindictive at least twice within the past 6 months. Hallmark of ODD Persistent angry irritable mood and defiant bx with vindictiveness Conduct disorder exhibits lack of empathy, aggression and impulsivity Severe behaviors violating society norms or rights of others and involved aggression towards others, animals, theft, destruction of property occurring in multiple settings Conduct disorder Conduct disorder has a developmental relationship with ODD When can conduct disorder start presenting as early as preschool more seriously appear later before 16 - Low tolerance of frustration and adversity, -Frequently impulsive/angry outburst (temper tantrums, verbal assaults, physical assaults towards others, animals, property) -Outbursts are unplanned, have a rapid onset, are out of proportion to the trigger that elected the response and does not last longer than 30 minutes -Verbal outbursts: twice a week for 3 months Intermittent explosive disorder description How often do intermittent explosive disorder verbal outbursts occur twice a week for 3 months What are the 8 facial features of FAS Skin folds at the corner of the eye Small head circumference Low nasal bridge Small eye opening Short nose Small midface Indistinct philtrum Thin upper lip Functional issues with FAS- ADLs Difficulties with sleeping, feeding in infancy and difficulties with self care Bx interventions indicated for FAS Training in social skills, problem solving, personal safety, assist students in improving special and functional skills - Relaxation, medication, art therapy, yoga, exercise, animal assisted therapy, vitamins/herbals, massage/reiki, energy work, acupuncture Benefits of early interventions for FAS Helps patient develop basic skills like walking, talking, interacting with others. It is a combo of pharm and nonpharmacy Pharmacology for FAS SSRI, alpha 2 agonist, anticonvulsant, stimulants, atypical antipsychotic PMHNP role in identifying early with diagnosis for disabilities education act A federal law to ensure kids with disabilities receive free appropriate education -IDEA Receive individualized special education services to address needs, receive preparation for employment and independent living, protected by law, federal agency, state/local/educational service agencies receive support IDEA- individuals with disabilities education act Risk factors for developing eating disorders -Fmly hx, close relative with an eating disorder -Weight stigma in the culture or family -Trauma (Physical or sexual abuse) -Hx of being bullied about weight or physical appearance -Biopsychological involving Se and Da Lab values for PICA CBC and zinc- iron deficiency anemia may cause pica) and a Lead level Lab alues for anorexia CBC- anmeia, thrombocytopenia, low WBC common in anorexia due to marrow response to starvation Lab values for bulimia Urea and electrolytes- dehydration, hypokalemia, hypochloremia, hyponatremia, metabolic alkalosis, hypomagnesemia, hypophosphatenmia Restrictive eating patterns, extremely low body weight intense fear of gaining weight, excessive exercise to control it. Anorexia Recurrent episodes of eating unusually large amounts of food paired with feeling a lack of control over eating, binge eating alone or in secrecy about eating or eating when not hungry Binge eating Recurrent episodes of eating unusually large amounts of food paired with a feeling of lack of control of eating behaviors. To compensate for overeating, individuals with bulimia nervosa engage in behaviors to prevent weight gain, including self-induced vomiting, excessive use of laxatives or diuretics, excessive exercise, fasting, or a combination of these behaviors - At least once a week for 3 months Bulimia Nervosa Persistent ingestion of nonfood items that do not contain nutritional value at least once a month. Clay paper soap hair soil chalk paint metal pebbles ice Pica Reduced intake of food volume or variety due to fear of aversive consequences of eating, lack of interest in food or eating or sensory sensitivity. Associated with nutritional, medical, or psychological impairment. Eating only a few foods that do not meet nutritional needs ARFID What dx criteria for AFRID Significant weight loss, nutritional deficiency, dependence of an E tube or nutritional supplements, impaired psychosocial functioning Pica tx Non contingent reinforcement, environmental enrichment, overcorrection What is the SCOFF tool used for eating disorders Content of SCOFF tool Sick: Eat until feeling sick Control: loss of control One: Have you recently lost one stone (14 pounds) in 3 mo Fat: Believe you're fat when others say you're too thin Food: Does food dominate your life Over 2 needs investigation What is one of the most successful tx for eating d/o in kids and teens Family based tx for eating d/o What are the 3 phases to family based tx for eating disorder Full parental control, gradual return of control, autonomy One's concept of oneself as male female or both that is not derived from an interconnection of biotraits, developmental influences, or environmental factors Gender identity At what age do kids become aware of the physical differences between boys and girls What age have kids established their gender identity 2 4 Social affirmations for gender Pronouns and gender expression like hairstyle or clothing A supportive family of gender dysmorphia increases Resilience for pt while a family that is resistant or discriminates cause significant distress Adolescent prevalence for alcohol 38.3% Adolescent prevalence for marijuana 24.6% Adolescent prevalence for tobacco 27.1% Adolescent prevalence for other drugs 9.2% CRAFFT tool content Car: Driven with someone high or drunk Relax: Use substances to relax/feel better about self Alone: Use substance alone Forget: Forget things you shouldn't while using Fmly/Friends: Tell you you should cut down Trouble: while using substance Over the last 12 months, 2 or more need further assessment What is the most prevalent intervention for adolescence with SUD Counseling- CBT, group contingency management, MI, 12 step program or peer to peer program Recurrent use of substances causing significant impairment including health problems, disability, or failure to meet responsibilities at home work or school Definition of addiction Can affect growth development of the brain and increase risky behavior like unprotected sex and impaired driving Addiction Represents conceptual framework and reveals how ACEs are strongly related to the development of risk factors for poor health and social consequences throughout the life course. ACEs pyramid Generational embodiment/Historical trauma →Social Conditions/Local Context→ACE→Disrupted neurodevelopment→Social/Emotional/Cognitive Impairment→Adoption of health risk bx→Disease/disability/social problems→Early death Steps of ACEs Family risk factors for ACEs -Caregiving challenges related to kids with disabilities, MH issues, chronic physical illness -Limited understanding of childs needs/development -Parents were abused/neglected -Young caregivers/single parents -Low income/education -high levels of parenting stress or economic stress -Isolation -High conflict and negative communication styles -Attitudes accepting of or justifying violence or aggression Factors that promote resilience - Close relation to caregiver -Caregiver knowledge and use of positive parenting skills -Sense of purpose (faith, culture, identity) -Individual competencies (problem solving, self regulation, autonomy -Opportunity to connect socially -Access to support services for parents and families -Community resources Elements of trauma informed care Safety: most fundamental to avoid retraumatizing Trust/Transparency: engage in kind interaction, empower Peer support: promo healing with shared experience Collaboration: Empower pt to engage in decisions Empowerment: Promotes self efficacy agency and dignity Cultural/Historical/Gender awareness: ACEs may bea. result of the following PTSD in kids manifestation include what kind of symptoms Dissociative (depersonalization derealization) Feeling detached from ones own body Depersonalization Feelings that ones surrounds are not reality Derealization 4 symptom categories of PTSD Intrusion, avoidance, negative cognitive mod/symptoms, arousal or reactivity What are the following symptoms categorized as for PTSD: Irritability and verbal or physical aggression Reckless or risk taking bx Hypervigilance Concentration difficulty Exaggerated startle response Sleep disturbances Arousal or reactivity What are the following symptoms categorized as for PTSD: Memory deficits surrounding traumatic event Exaggerated negative beliefs of self or environment Distorted cognitions and self blaming behaviors related to the cause/consequence of trauma Persistent negative emotions (guilt, anger, fear, shame) Feelings of detachment from others Persistent inability to experience positive emotions Social w/d in kids under 6 Negative cognitive mood symptoms What are the following symptoms categorized as for PTSD: Avoidance of distressing memories/thoguhts/feelings Avoidance of reminders like people, places, situations Avoidance What are the following symptoms categorized as for PTSD: Recurrent/intrusive memories of trauma, children engage in repetitive play expressing trauma themes Distressing dreams/nightmares Dissociative reactions or flashbacks Intense psychological/physiological reactions when exposed to cues the symbolize ore represent an aspect of trauma Intrusion When do s/s occur for PTSD Within the first 3 months and at least for 1 month the development of emotional or behavioral symptoms within 3 months of the onset of a new stressor, with significant impairment in social or occupational functioning but do not persist past 6 months after the initial stressor has resolved. Adjustment disorders The child's symptoms have been present for 2 months; Adjustment disorder is most likely PTSD symptoms must be present for how long? 1 month Adjustment disorder specifiers Depressed mood, anixety, mixed anxiety & depressed mood, disturbance of conduct, mixed disturbance of emotions and conduct What has no clear resolution such as physical disability or living in a community with high crime rates. ACEs are at risk persistent adjustment disorder Stimulant Medications: Methylphenidate -Low risk of adverse effects -Available formulations: • Ritalin - available in immediate release (IR) and extended release (XR) available in beads that may be sprinkled on food for children who cannot swallow pills • Concerta biphasic - combined immediate and delayed release in one medication • Daytrana - patch applied in AM and removed after 9 hour Stimulant Medications: Dexmethylphenidate (Focalin) -Available in IR and ER -More potent than Ritalin -High risk of adverse effects Stimulant Medications: Amphetamine (Adzenys) -available in orally disintegrating ER formula for children who cannot swallow pills -Avoid prescribing when an MAOI has been used within 14 days Stimulant Medications: Dextroamphetamine (Adderall) -Available in IR and extended-release formulations -Often dosed in morning (IR or XR) with an evening or evening prn (IR) dose if med effects diminish prior to end of school, study or the workday -Most abused & diverted prescription stimulant Stimulant Medications: Lisdexamfetamine (Vyvanse) -Biologically inactive until metabolized by the body (Prodrug) -Less abuse & diversion potential than other stimulants -Higher-cost medication Non-stimulant medication: Atomoxetine (Strattera) -Noradrenergic (NRI) -Initial drug of choice for adults with ADHD -no abuse potential -tolerated well when prescribed in BID dosing -appropriate choice for comorbid substance abuse -may augment the effects of antidepressants & antianxiety meds -can be dosed at bedtime if fatigue is noted -unlikely to worsen tics Non-stimulant medication: Clonidine -α 2 agonist • May be taken as monotherapy or with stimulant medications -enhances precortical function for better mental focus -appetite neutral -may help with sleep disturbances, administer at bedtime -adverse effects: • sedation, brain fog -monitor of BP closely during initial titration, risk of hypotension -tapered to avoid rebound hypertension post discontinuation Non-stimulant medication: guanfacine -α 2 agonist • May be taken as monotherapy or with stimulant medications -may also be used for children with tics, sleep disturbances, or aggression -tolerability & convenience enhanced by once-daily oral controlled-release formulation -adverse effects: • sedation, headache, decreased appetite -reduced side-effect profile comparable to clonidine -bedtime administration to avoid daytime sedation Non-stimulant medication: Bupropion (Wellbutrin) -Norepinephrine Dopamine Reuptake Inhibitor -off-label use for ADHD in adults -appropriate for clients with concurrent depression or tobacco abuse Attention-deficit/hyperactivity disorder (ADHD) -one of the most common neuropsychiatric disorders -approximately 9.4% of children in the U.S. -more frequently males than females, ratio 2:1 -symptom burden mild to severe -characterized by consistent pattern of inattention &/or hyperactivity & impulsivity that interferes with functioning & development • affect development of proper cognitive, behavioral, emotional, social, & academic function -hyperactivity and impulsivity ADHD subtype symptoms: excessive fidgeting or talking, feelings of restlessness and impatience, frequent interruption, and difficultly playing quietly -inattentive ADHD subtype symptoms: difficulty organizing tasks, maintaining a routine, and paying attention to detail • may not be distinguishable until eight or nine years of age -primarily disrupts neuronal connections within the frontal lobe & prefrontal cortex Without early identification and proper treatment, ADHD can cause disruptions in: academic performance family stress difficulties in social relationships accidental injuries ADHD is associated with: increased rates of depression & SUD Symptoms of ADHD -Selective Attention • Lack of attention to detail • Careless mistakes • Not listening • Losing things • Diverting attention • Forgetfulness -Lack of Sustained Attention • Poor problem solving • Difficulty completing tasks • Disorganization • Difficulty sustaining mental effort -Impulsivity • Excessive talking • Blurting things out • Not waiting for one's turn • Interrupting -Hyperactivity • Fidgeting • Leaving one's seat • Running, climbing • Trouble playing quietly When is ADHD most often diagnosed -preschool and elementary school • inattentive features become more prominent ADHD Lifespan Considerations: Symptoms Change with Age -Young children with ADHD • often have developmental delays • may engage in behaviors less mature than peers -Teens with ADHD at risk for: • poor academic performance • problems with driving • difficulties with social situations • risky sexual behavior • substance abuse -75% of children with ADHD experience symptoms in adulthood -Adolescents & Adults with ADHD • may struggle with executive function, attention, working memory • problems with day-to-day functioning, performance at work, relationships ADHD is a deficiency of neurotransmitters, mainly _________ & _________ dopamine and norepinephrine ADHD diagnostic criteria -A pattern of at least six symptoms of inattention and/or hyperactivity-impulsivity that interfere with functioning or development. -Symptoms persist for six months or longer. -Symptoms interfere with social, academic, or occupational functioning. -Symptoms are present in two or more settings • for instance, home & school Kelsey is a 7-year-old first-grader who is the youngest of four children. During parent teacher conferences, her teacher reported that she is polite, respectful, and gets along well with her peers. She has a hard time keeping her desk neat and she frequently misplaces her supplies and loses library books. She must often be told more than once to complete instructions. Her work is appropriate for her grade level, but she often makes careless mistakes on her assignments. She struggles with math and avoids doing arithmetic assignments. Her parents endorse that Kelsey's room is "sloppy" but do not notice any of the other concerns in the home environment. What is the most likely diagnosis for Kelsey? ADHD predominantly inattentive presentation ADHD predominantly hyperactive-impulsive ADHD combined presentation unlikely ADHD diagnosis ADHD predominantly inattentive presentation Rationale: Kelsey meets diagnostic criteria for ADHD with a predominantly inattentive presentation. Inattentive symptoms include lack of attention to detail, making careless mistakes, difficulty listening and following instructions, frequent disorganization and misplacing items, distractibility, avoiding tasks that require sustained mental effort, and forgetfulness. Although Kelsey's parents identify only one symptom in the home setting, she exhibits multiple symptoms in the school setting. Logan is a 6-year-old kindergartener who has a newborn sister. His parents are concerned that Logan seems to be unable to occupy himself quietly when his sister is napping. Logan interrupts both his parents and other adults in the home who come to visit his sister. He gets impatient when his questions are ignored by adults. His parents endorse that the behaviors began about the same time as his mom's pregnancy was announced. Logan's teacher does not endorse the same behaviors at school; his teacher states he is quiet, reserved, and plays well with others. What is the most likely diagnosis for Logan? ADHD predominantly inattentive presentation ADHD predominantly hyperactive-impulsive presentation ADHD combined presentation unlikely ADHD diagnosis unlikely ADHD diagnosis Rationale: Although Logan has some symptoms that are consistent with a diagnosis of ADHD, the symptom onset coincides with his mother's pregnancy. There are no concerns of symptoms at school; more information is needed to assign a diagnosis of ADHD. Xander is an 8-year-old second-grader who is the youngest of two children. His mother notes that he acts as if he has "non-stop energy." He pesters and interrupts his older sister to play when she is reading or doing homework, and he has little patience for completing his homework. Xander's mom endorses that his behavior has been consistent for the past few years. Xander's teacher notes that he fidgets during seat time, speaks out of turn in class, and runs or skips in the halls. What is the most likely diagnosis for Xander? ADHD predominantly inattentive presentation ADHD predominantly hyperactive-impulsive presentation ADHD combined presentation unlikely ADHD diagnosis ADHD predominantly hyperactive-impulsive presentation Rationale: Xander meets diagnostic criteria for ADHD with a hyperactive-impulsive presentation, including fidgeting, "non-stop" energy, difficulty in engaging in quiet activities, speaking out of turn, excessive running, and interrupting others. The behaviors occur in school and at home and have been present consistently for several years. Belle is a 10-year-old fourth-grader who is the oldest of two children. During parent teacher conferences, her teachers expressed concerns that she has difficulty listening and paying attention in class. She plays with her pencil and eraser constantly during lessons and, when she does pay attention, she blurts out answers to questions without waiting to be called upon. She talks to her peers during class and often interrupts the teacher to share with the class. Belle often forgets to bring her backpack or lunch to school and often leaves school without her jacket. Belle's mother notes that her daughter has always been talkative and energetic; she has difficulty keeping her things organized and must be reminded of daily chores, such as feeding her hamster. What is the most likely diagnosis for Belle? ADHD predominantly inattentive presentation ADHD predominantly hyperactive-impulsive presentation ADHD combined pres ADHD combined presentation Rationale: Belle meets diagnostic criteria for ADHD combined presentation. She has several symptoms of hyperactive-impulsive presentation, including fidgeting, speaking out of turn, excessive talking, and interrupting. She also has symptoms of inattentive presentation, including difficulty listening, paying attention, forgetfulness, and difficulty with organization. Although her symptoms at school differ from those seen at home, she has symptoms in both environments. Rating scales for ADHD -ADHD Rating Scales (ADHD-RS-IV and 5) -Swanson, Nolan and Pelham (SNAP) scale -Adult ADHD Self Report Scale (ASRS) -Vanderbilt scales -Conners' scales ADHD Comorbidities 2/3 of children dx'd with ADHD have at least one coexisting psychiatric condition -learning disabilities -conduct disorders -tics -anxiety -depression -language disorders -SUD's • adolescents at increased risk *often tx ADHD 1st then comorbidities, may reduce overall stress levels, provide clearer picture of comorbid symptoms Tenzing is a 15-year-old who presents with restlessness, distractability, impulsive behavior, and inattention at school. He sleeps very little most nights and is often irritable. His parents describe him as "moody" and state that the smallest changes cause his mood to shift. He has had these symptoms for a few years, but recently the symptoms have gotten worse. The PMHNP diagnoses Tenzing with ADHD. Which of the following is the most likely comorbid diagnosis for Tenzing? bipolar disorder (BPD) unipolar depression generalized anxiety disorder bipolar disorder (BPD) Rationale: After beginning medication for ADHD, Tenzing's remaining symptoms are consistent with bipolar disorder. Although mood dysregulation is common in clients with ADHD, mood changes are typically situational. Bipolar disorder presents with more random and cyclical mood changes. Both ADHD and BPD can present with irritability, sleep issues, restlessness, and impulsive behavior. Onyenna is a 12-year-old whose teacher has concerns related to her school performance. She makes careless mistakes with her work and has difficulty listening in class and following directions. She frequently forgets to bring homework assignments and misplaces her personal belongings. She appears fatigued most days and complains of being tired frequently. Onyenna's parents endorse that she always seems irritable and disorganized at home, and they often have to ask her to complete tasks more than once. Onyenna states that she has no interest in school or extracurricular activities and does not care that she is not doing well in her classes. The PMHNP diagnoses Onyenna with ADHD and prescribes atomoxetine 25 mg once daily. Which of the following is the most likely comorbid diagnosis for Onyenna? bipolar disorder (BPD) unipolar depression generalized anxiety disorder learning disability unipolar depression Rationale: After beginning medication for ADHD, Onyenna's remaining symptoms are consistent with unipolar depression. In children, depression often presents with irritability, fatigue, and a decreased interest in school or peer activities. Both ADHD and depression can cause diminished concentration and attention. Forgetfulness, carelessness, difficulty following directions and disorganization are common symptoms of ADHD with a predominantly inattentive presentation. Elijah is a 6-year-old whose teacher is concerned with his behavior at school. She reports that he is frequently irritable. He gets angry when he must wait his turn for an activity, and often speaks out of turn, interrupts, and talks "nonstop." He has difficulty sitting still. Elijah's custodial grandmother endorses that he has high energy at home. She also notes that he loses his temper often and appears to purposely antagonize his older sister. He often blames her for leaving messes around the house that are his. He argues with both his grandparents when asked to complete chores. The PMHNP diagnoses Elijah with ADHD and prescribes methylphenidate extended-release 20 mg daily. Which of the following is the most likely comorbid diagnosis for Elijah? bipolar disorder (BPD) oppositional defiant disorder conduct disorder generalized anxiety disorder learning disability oppositional defiant disorder Rationale: After beginning medication for ADHD, Elijah's remaining symptoms are consistent with oppositional defiant disorder (ODD), which presents with symptoms including anger, arguing with adults, refusing to follow rules, deliberately annoying others, and blaming others for their mistakes. Both ADHD and ODD can present with irritability. Interrupting, talkativeness and high energy are common symptoms of ADHD with hyperactive-impulsive presentation. ADHD tx -multimodal, often requiring medical, educational, behavioral, & psychological intervention -Pharmacologic • stimulants effective for 70-80% of clients meds of choice for children • non-stimulants used when client doen't respond to stimulant meds used when stimulants are contraindicated can help lower distractibility, improve attention, working memory, & impulsivity -combination sometimes used • when argumentative or oppositional symptoms ADHD tx clinical pearls • Stimulant - ECG req if cardiac hx present in a first-degree relative • Monitor BP, height, weight regularly during tx • Assess for bipolar disorder before tx. CNS stimulants may cause psychotic or manic symptoms or may exacerbate behavior disturbance symptoms and thought disorders in clients with pre-existing psychosis. • CNS stimulants may exacerbate comorbid anxiety and substance use disorders. • Tx efficacy noted within first week • Increased irritability & insomnia tx'd with low dose of nonstimulant med • stimulants may unmask the presence of tics • Switching stimulants, D/C current med & start new med at a starting dose the next day ADHD Prescribing Advisory -Several stimulant meds are Schedule II indicating high potential for abuse • short-acting meds are at higher risk for diversion -Occasional urine drug screens should be obtained • verify the presence of amphetamines and the absence of other substances of abuse Education for clients taking stimulant medications includes: -common side effects: • restlessness, irritability, anxiety, insomnia, stomachache, headaches, tics, worsening aggression symptoms -worsening of symptoms or "crash" may occur when med wears off • especially with IR meds -take med with breakfast to decrease anorexia or associated weight loss Teddy is a 7-year-old who was diagnosed with ADHD with hyperactive-impulsive presentation. The PMHNP prescribed dexmethylphenidate extended-release 10 mg once daily. His mother has been giving him the medication before school. Teddy's teachers report that his symptoms are much improved, but his parents note that he has a significant rebound of symptoms in the late afternoon, and he struggles on days he has homework and after-school activities. Which of the following medication adjustments are appropriate for Teddy? prescribe a daily afternoon dose of dexmethylphenidate immediate release 2.5 mg in addition to the morning dose increase the daily dose of dexmethylphenidate extended-release to 20 mg recommend a PRN afternoon dose of dexmethylphenidate 5mg IR when Teddy has after school commitments switch to lisdexamfetamine dimesylate 10 mg daily add atomoxetine 0.5mg/kg/day prescribe a daily afternoon dose of dexmethylphenidate immediate release 2.5 mg in addition to the morning dose Rationale: Although long-acting medications typically act for 8-12 hours, some clients experience a shorter window of symptom control. A "booster" dose of short-acting stimulant medication can reduce problems of rebound when the earlier dose wears off. Josué is an 11-year-old who was diagnosed with ADHD combined presentation. He was prescribed amphetamine/dextroamphetamine immediate release 10mg twice daily. He takes the medication in the morning and after school. His symptoms have improved; however, he now complains of difficulty falling and staying asleep. Which of the following medication adjustments is appropriate for Josué? Select all that apply. switch to amphetamine/dextroamphetamine extended-release 20 mg daily decrease the dose of amphetamine/dextroamphetamine immediate release to 5 mg twice daily decrease the frequency of amphetamine/dextroamphetamine immediate release to once daily recommend sleep hygiene techniques prescribe zolpidem as needed switch to amphetamine/dextroamphetamine extended-release 20 mg daily recommend sleep hygiene techniques Rationale: Stimulant medications may cause sleep disturbances, especially if the doses are taken later in the day. Amphetamine/dextroamphetamine immediate release has a duration of 4-8 hours, while extended-release has a duration of 8-12 hours. Switching to extended-release dosing and improving sleep hygiene may help improve sleep. Alternatively, the second dose of amphetamine/dextroamphetamine immediate release can be taken earlier in the day. Addison is a 9-year-old who was diagnosed with ADHD predominantly combined presentation and was prescribed methylphenidate extended-release chewable tablets 20 mg once daily. Since she has started taking the medication, her appetite has decreased. She is 51 inches tall, and her initial weight was 58 lbs. She has lost 8 lbs. since beginning treatment. Which of the following medication adjustments is appropriate for Addison? implement stimulant holidays on weekends and non-school days decrease the dosage of methylphenidate extended-release to 10 mg daily switch to methylphenidate immediate-release 20 mg once daily switch to atomoxetine 25 mg once daily implement stimulant holidays on weekends and non-school days Rationale: Stimulant holidays combined with caloric supplementation and monitoring can help offset stimulant-related weight loss. Switching to a non-stimulant medication may be warranted if drug holidays do not provide the desired result of weight stabilization. ADHD nonpharmacologic tx -Schools • educational support, behavioral interventions in the classroom, and accommodations -Psychotherapy • CBT • social and organizational skill training • family therapy. • Under age 6 American Academy of Pediatrics (AAP) recommends parent training in behavior management as a first-line intervention ADHD parent training in behavior management -What parents learn: • Positive Communication • Positive Reinforcement • Structure and Discipline ADHD complementary and alternative medicine (CAM) interventions -dietary approaches -nutritional supplements -mind/body practices • exercise • yoga • meditation -brain training programs disruptive behavioral disorders -Disruptive, impulse-control, & conduct disorders -problems with emotional & behavioral regulation -often violate others' rights -bring ind. into conflict with social norms & authority figures -Behaviors often severe, frequent, occur in varied settings, can have serious consequences -more common in boys than girls -first onset in childhood or adolescence -Common diagnosis: • oppositional defiant disorder • conduct disorder • intermittent explosive disorder Oppositional Defiant Disorder (ODD) -hallmark: persistent angry & irritable mood, argumentative & defiant behavior, & vindictiveness -behavioral features may present with or without (-) mood -symptom expression in one setting • commonly the home • severe cases symptoms may present in various settings -symptom expression impairs social functioning of the ind. • more evident, interactions with peers or adults they know -Onset: early childhood • symptoms commonly persist into adulthood -frequently occurs comorbidly with ADHD & often precedes development of conduct disorder -high co-occurrence rates with anxiety & MDDs -associated with increased risk for suicide ideation -Prevalence rates: 1%-11%, more prevalent in boys than girls ODD diagnosis -behaviors must have (-) consequences & must not be associated exclusively with a psychotic, substance use, depressive, or bipolar disorder. • must also not meet diagnostic criteria for DMDD -First, 4 or more of the following symptoms must have occurred during an interaction with one or more individuals that are not siblings within the last 6 months: • Angry/Irritable Mood often loses temper is often easily annoyed is often angry and resentful • Argumentative/Defiant Behavior argues with authority figures or adults actively defies or refuses to follow rules or requests from authority figures deliberately annoys others blames others for their mistakes or misbehavior • Vindictiveness has been spiteful or vindictive at least twice within the past 6 months -Second, symptom persistence & frequency must exceed typical developmental behaviors r/t the child's age, gender, & culture. • For children under age 5, behaviors must occur on most days for at least six months. • For people 5 and older, the behaviors must occur at least once per week for at least six months. The severity of ODD is determined by: the number of settings in which the behaviors occurred. ODD and DMDD Diagnosis Considerations -DMDD shares many symptoms with ODD, many individuals meet diagnostic criteria for both disorders • ODD cannot be diagnosed if criteria are also met for DMDD. These circumstances, should receive a diagnosis of DMDD ODD stigma -reactive behavior & trauma responses are mischaracterized as self-control issues -Some mental health providers are calling for a revision of the DSM-5-TR ODD • use neutral terminology, behavior (reactive) or state (dysregulated) rather than a disposition (oppositional and defiant) Conduct disorder -severe behaviors that violate societal norms or the rights of others, may involve aggression towards others, animals, theft, &/or the destruction of property -developmental relationship between ODD & conduct disorder -Behaviors may present as early as pre-school, though more serious symptoms tend to appear later in childhood or adolescence before age 16 • occur in multiple settings, freq cause significant dysfunction -increased risk of: • criminal behaviors & substance-related disorders especially those with childhood-onset type • mood & anxiety disorders • impulse-control disorders • psychotic disorders • PTSD -prevalence: 1.5%-3.4% in the U.S., occurs more in males risk factors for conduct disorder -Temperamental • Difficult infant temperament • lower-than-average intelligence -Environmental: Family-Level • caregiver abuse and neglect • varying caregivers or child-rearing practices • harsh discipline • family criminality • substance-related disorders -Environmental: Community-Level • rejection by peers • participation in a delinquent peer group • poverty • exposure to violence -Genetic or Physiological • Family members with conduct disorder • depressive & bipolar disorders • schizophrenia • ADHD • substance use disorders Conduct Disorder DSM-5-TR Diagnosis 3 or more of the following symptoms in the past 12 months with one symptom occurring within the last 6 months: -Aggression to People and Animals • Bullies, threatens, or intimidates others • Initiates physical fights • Uses a weapon • Physically cruel to people or animals • Theft with confronting a victim • Forces another into sexual activity -Destroys Property • Uses arson to destroy property • Uses methods other than arson to destroy property -Deceitfulness or Theft • Vandalism • Lies to obtain goods or favors • Theft without confronting a victim -Serious Violations of Rules • Stays out at night, before aged 13 • Runs away from home overnight at least twice • Truant from school, before aged 13 *must cause significant impairment & not fulfill diagnostic criteria for antisocial personality disorder Conduct Disorder subtypes -based on the age at onset: • childhood-onset symptoms before age 10 • adolescent-onset symptoms after age 10 • unspecified-onset subtype when the age at onset is unknown. Conduct disorder pharmacologic tx -atypical antipsychotics -SSRIs -Mood stabilizers -Beta blockers *Main component of tx is psychotherapy Intermittent explosive disorder (IED) -low tolerance for frustration & adversity -essential features: freq impulsive or angry outbursts, often include temper tantrums, verbal assaults, or physical assaults towards others, animals, or property • unplanned • rapid onset • out of proportion to the trigger that elicited the response • lasts no longer than 30 minutes -Verbal outbursts: average of twice a week for three months -behavioral outbursts or tantrums that involve the destruction of property within 12 months -outbursts often lead to subjective distress or social or occupational dysfunction and poor life satisfaction and quality of life for the affected individuals. Seamus is a 13-year-old who was referred to the psychiatric mental health nurse practitioner (PMHNP) by a family court judge for evaluation. Seamus was arrested after breaking into several cars on his street overnight and stealing loose change and small electronics. Seamus's parents endorse that he has had problems since he was a young boy. Starting in kindergarten, he has had "anger management" issues and argues with his parents and with teachers. He has difficulty sitting still in the classroom and was frequently disciplined for interrupting teachers, talking constantly, and running in the halls. At home, he often exhibits vindictive behavior towards his siblings and blames them for his actions. His parents describe him as "driven by a motor." He is irritable most of the time. He has never liked school and has struggled academically since first grade. He was suspended twice in elementary school for bullyi Yes According to the DSM-5-TR, does Seamus meet the diagnostic criteria for conduct disorder? yes no unable to determine Yes According to the DSM-5-TR, does Seamus meet the diagnostic criteria for intermittent explosive disorder? yes no unable to determine No According to the DSM-5-TR, does Seamus meet the diagnostic criteria for ADHD? yes no unable to determine Yes Rationale: Seamus meets diagnostic criteria for ODD, conduct disorder, and ADHD. His symptoms consistent with ODD include anger and irritability, argumentative and vindictive behavior, and blaming others. Symptoms consistent with conduct disorder include a history of repetitive, persistent behavior that violates societal norms within the past twelve months, including bullying, fighting, vandalism, theft, and truancy. His symptoms consistent with ADHD include "non-stop" energy, speaking out of turn, talkativeness, excessive running, and interrupting others. The behaviors occur in school and at home and have been present consistently for several years. His behaviors have negatively impacted his academic performance to the extent that he has been expelled from school. disruptive, impulse-control, and conduct disorders assessment and screening -comprehensive psychiatric evaluation • family hx • parenting styles • developmental hx • academic records -child-rated, caregiver-rated, and clinician-rated tools • Minnesota Impulse Disorders Interview (MIDI) diagnostically valuable Tx of disruptive disorders -reducing (+) reinforcement for undesirable behaviors -encouraging prosocial behaviors -nonviolent forms of discipline -following consistent parenting strategies -interventions: • Group parent-caregiver training programs • Individual parent-caregiver training • Group child-focused programs • Cognitive problem-solving skills training • School-based programs • Medication Collaborative and Proactive Solutions (CPS) -Lives in the Balance is an organization promotes an evidence-based treatment model for children with disruptive behaviors -model focuses on identifying the underlying problems that may be causing concerning behaviors and working collaboratively with children to address the problems -organization provides educational materials and support for parents, educators, and healthcare providers -Lives in the BalanceLinks to an external site. is one resource PMHNPs can provide to help parents and educators navigate disruptive behaviors in the home and school settings. Fetal alcohol spectrum disorder (FASD) -umbrella term • describes the physical, mental, behavioral, &/or learning disabilities that can occur in an individual who was prenatally exposed to alcohol -Fetal alcohol syndrome (FAS) • most involved dx on the spectrum -lifelong disability -estimate 1-5 school children per 100 in U.S. & Western Europe - estimated annual cost, FAS in US $4 billion FASD Effects of Development and Behavior -Cognitive • Problems with memory & learning, especially math • Poor reasoning & limited executive function • Problems with attention • Intellectual disability -Physical • Prenatal growth deficits • Poor motor skills & coordination • Vision & hearing problems • Problems with heart, bones, kidneys • Short stature & low body weight • Small head size • Abnormal facial features -Behavioral problems • Poor social skills • Poor emotional control • Impulsivity • Hyperactivity -Functional • Difficulties with sleep & feeding in infancy • Difficulties with self-care Types of FASD -Fetal alcohol syndrome (FAS) -Partial FAS (pFAS) -Alcohol-related neurodevelopmental disorder (ARND) -Alcohol-related birth defects (ARBD) -Neurobehavioral disorder associated with prenatal alcohol exposure (ND-PAE) FASD interdisciplinary evaluation may include: collaboration with a primary care provider, developmental pediatrician, geneticist, psychologist, social worker, speech-language pathologist, occupational therapist, or educational specialist Facial Dysmorphia -Requirement for the dx of the most severe forms of FASD • FAS, and pFAS -requires presence of facial dysmorphia • including narrow eyes, a smooth philtrum between the nose & mouth, & a thin upper lip -most children with FASD do not display facial dysmorphia • 80.1% with FASD are missed • 6.4% misdiagnosed when diagnosed primarily based on presence of physical markers Facial features of FAS Skin folds at the corner of the eye Small head circumference Low nasal bridge Small eye opening Short nose Small midface Indistinct philtrum (groove between nose and upper lip) Thin upper lip FASD treatment -based on the severity of symptoms & developmental impact -Prognosis: best if children receive dx & begin tx before age 6 -combines pharmacological & nonpharmacological approaches -Pharmacologic • SSRIs, antidepressants, alpha2 agonists, anticonvulsants, stimulants, and atypical antipsychotics -Nonpharmacologic • Behavioral interventions & training in social skills, problem-solving, & personal safety • School-based interventions, such as speech & occupational therapy, behavioral supports, & accommodations • Family support groups & parent education FASD complementary and alternative therapies Relaxation therapy Meditation Art therapy Yoga and exercise Acupuncture and acupressure Massage, Reiki, and energy work Vitamins and herbal supplements Animal-assisted therapy Educational Support -critical for providing opportunities to children diagnosed with: • ADHD • disruptive, impulse-control, & conduct disorders • FASD - federal law designed to ensure that children who have disabilities receive free appropriate public education (FAPE) the Individuals with Disabilities Education Act (IDEA) -Initially passed in 1975 -IDEA ensures that: • Children with an identified disability receive individualized special education & services that address their needs. • Children with disabilities receive preparation for employment & independent living. • Children & families impacted by disability are protected under the law. • Federal agencies, states, localities, & educational service agencies that provide educational assistance to children with disabilities receive support. protects the rights of individuals with disabilities who are enrolled in programs receiving federal financial assistance through the U.S. Department of Education Section 504 of the Rehabilitation Act of 1973 -Support typically provided through implementation of Individualized Education Plans (IEP) or 504 plans • describe the services & accommodations that will be provided to students with qualifying disabilities Types of Feeding and Eating Disorders -Anorexia nervosa -Bulimia nervosa -Binge eating disorder -Pica -avoidant/restrictive food intake disorder (ARFID) With repeated ingestion of a drug, the drug shows decreased effect. Increasing doses are required to achieve the effects noted with the original administration. Tolerance State of adaptation produced with repeated administration of certain drugs so that physical symptoms occur when the drug is discontinued abruptly. Dependence A change in behavior caused by biochemical changes in the brain after continued substance use characterized by preoccupation with and repeated use of a substance despite of negative outcomes. Addiction Physiological and psychological reactions that occur when the use of a substance is stopped abruptly. Withdrawal Condition following the ingestion of a substance resulting in changes in level of consciousness, cognition, perception, judgment, and behavior. Intoxication Feeding and Eating Disorders Background -severe, persistent disturbances in eating behaviors -approx. 9% of pop. in U.S. • costing $64.7 billion per year -second deadliest mental health condition, after opioid overdoses • approx. 10,200 deaths per year -typically develop in adolescence or young adulthood -more common in women -serious physical effects, contribute to psychological distress, disruptions in social functioning Feeding and Eating Disorders Risk Factors -Complex biopsychosocial factors -may experience neurobiological differences • serotonin and dopamine -Cultural norms • idealize a thin appearance -Genetics -Biochemical factors -Psychological factors -Trauma from abuse or bullying -Family dysfunction -Emotional needs not met -Cultural factors Which of the following factors impact the development of eating disorders? Select all that apply. parental attitudes to gender roles having a close relative with an eating disorder weight stigma in the culture trauma intense family expectations related to physical appearance having a close relative with an eating disorder weight stigma in the culture trauma intense family expectations related to physical appearance Rationale: Family history that includes a close relative with an eating disorder, weight stigma in the culture or family, trauma (especially physical or sexual abuse), and a history of being bullied about weight or physical appearance may increase the risk for eating disorders. Which of the following are common characteristics of individuals with eating disorders? Select all that apply. perfectionism low self-esteem high levels of responsibility narcissism perfectionism low self-esteem Rationale: Clients with eating disorders sometimes present with a negative, subjective appraisal of themselves, perfectionism, body image dissatisfaction, and a history of an anxiety disorder. Anorexia Nervosa -characterized by restrictive eating patterns, extremely low body weight, and an intense fear of gaining weight -may engage in excessive exercise as means of controlling weight -affects 1-2% of pop. • 0.3% of adolescents Anorexia Nervosa DSM-5-TR dx requires each of the following: -restriction of intake leads to significantly low body weight in the context of age, sex, developmental trajectory, and physical health -intense fear of gaining weight or of becoming fat or persistent behavior that interferes with weight gain -disturbance in the way in which one's body weight or shape is perceived, undue influence of body weight or shape on self-evaluation, or lack of recognition of the seriousness of the current low body weight severity of anorexia nervosa based on BMI: -Mild: Less than or equal to 17 kg/m2 -Moderate: BMI 16 to 16.99 kg/m2 -Severe: 15 to 15.99 kg/m2 -Extreme: Less than 15 kg/m2 anorexia nervosa medical complications impact most major organ systems -Cardiovascular • Structural changes • Functional changes -Gynecologic & Reproductive • Secondary amenorrhea, Decreased libido, pregnancy complications. -Endocrine • hypothalamic-pituitary abnormalities, contribute to severe bone loss -Gastrointestinal • diarrhea, constipation, elevated LFTs, SMA syndrome, pancreatitis, GERD, dysphagia -Renal & Electrolytes • Decreased GFR; diuresis, hyponatremia, dehydration -Pulmonary • dyspnea, pneumonia -Hematologic • Cytopenia, bone marrow changes -Neurologic • Wernicke encephalopathy, Korsakoff syndrome, brain atrophy, other brain structure changes -Dermatologic anorexia nervosa Dermatologic Cutaneous manifestations: -Xerosis (dry, scaly skin) -Lanugo-like body hair (fine, downy, dark hair) -Telogen effluvium (hair loss) -Carotenoderma (yellowing) -Acne -Hyperpigmentation -Seborrheic dermatitis (erythema and greasy scales) -Acrocyanosis (cold, blue, and occasionally sweaty hands or feet) -Perniosis (painful or pruritic erythema) -Petechiae -Livedo reticularis (reddish-cyanotic circular patches) -Paronychia (inflamed lateral and posterior nail folds) -Pruritus -Striae distensae (erythematous or hypopigmented linear patches) -Slower wound healing _____% of individuals with anorexia nervosa excessively exercise 40-80% -behavior often described as compulsive -excessive exercise • interferes with important tasks • exceeds 3 hrs/day • causes distress if unable to exercise • done at inappropriate times/places, no attempt to stop • done despite serious injury, illness, medical complications • beyond amount of calories consumed that day excessive exercise short term issues dehydration fatigue chronic back pain injuries strains and sprains stress fxs excessive exercise long term complications osteoporosis degenerative arthritis inability to menstruate reproductive issues heart issues _________ are common in individuals with anorexia nervosa mood swings -major changes in mood and personality • happy and energetic to listless in hours can be due to imbalance in serotonin, dopamine, oxytocin, cortisol & leptin Which of the following are DSM-5-TR diagnostic criteria for anorexia nervosa? Select all that apply. -refusal to maintain a minimal bodyweight -pathological fear of gaining weight -distorted body image in which clients continue to insist they are overweight even when emaciated -refusal to maintain a minimal bodyweight -pathological fear of gaining weight -distorted body image in which clients continue to insist they are overweight even when emaciated Rationale: Anorexia nervosa is an eating disorder where the main features include a refusal to maintain minimal body weight, a pathological fear of gaining weight, and a distorted body image in which sufferers continue to insist they are overweight. Which of the following symptoms is consistent with anorexia nervosa binge eating/purging type? avoiding eating to help control weight gain not being bothered about weight gain regularly using laxatives eating only certain types of foods regularly using laxatives Rationale: Binge eating/purging type anorexia nervosa is a type of eating disorder that involves regularly engaging in purging activities, such as vomiting or the misuse of laxatives, diuretics, or enemas, to help control weight gain. Bulimia Nervosa -recurrent episodes of eating unusually large amounts of food paired with a feeling of lack of control of eating behaviors • compensate for overeating, engage in behaviors to prevent weight gain; self-induced vomiting, excessive use of laxatives/diuretics, excessive exercise, fasting, or combination -lifetime prevalence rate: 1.5% in women -Comorbidities: most experiencing 1+ concomitant conditions, including depression, anxiety, & SUD -significant % have symptoms that meet criteria for personality disorders, most especially borderline personality disorder DSM-5-TR diagnosis of bulimia nervosa requires each of the following: -recurrent incidents of binge eating characterized by: • eating an amount of food in a discrete period that is notably larger than what most individuals would eat in a similar time period, under similar conditions • lack of control of overeating behaviors during the episode, such as feeling that one cannot stop eating or control how much is eaten -recurrent inappropriate behaviors to compensate for overeating to prevent weight gain, including self-induced vomiting; misuse of laxatives, diuretics, or other medications; fasting; or excessive exercise -binge eating and inappropriate compensatory behaviors occur, on average, at least once a week for 3 months -body shape & weight unduly influence self-evaluation -disturbance does not occur exclusively during episodes of anorexia nervosa. bulimia nervosa Medical Complications Some r/t malnutrition, while others r/t purging behaviors -Dental • Enamel erosion • Hot/cold sensitivity • Discoloration • Dental caries • Gum disease -Endocrine • Menstrual irregularities • Osteopenia & osteoporosis • Diabetes -Gastrointestinal • Parotid and submandibular (salivary) gland hypertrophy, with puffy or swollen cheeks • Laryngopharyngeal reflux • Loss of gag reflex • Esophageal dysmotility • Abdominal pain and bloating • Mallory-Weiss syndrome (esophageal tears) • Esophageal rupture (Boerhaave syndrome) • Gastroesophageal reflux disease (GERD) • Barrett's esophagus • Gastric dilation • Diarrhea and malabsorption • Steatorrhea • Protein-losing gastroenteropathy • Hypokalemic ileus • Colonic dysmotility • Constipation • Irritable bowel syndrome • Melanosis coli • Cathartic colon • Rectal prolapse • Pancreatitis Renal & Electrolytes • Dehydration • Hypokalemia • Hypochloremia • Hyponatremia • Metabolic alkalosis • Hypomagnesemia • Hypophosphatemia Binge Eating Disorder (BED) -hallmark: episodes of the consumption of excessively large amount of food accompanied by a sense of loss of control over the experience -recurrent episodes of binge eating, along with distress or secrecy about eating or eating when not hungry -first described in the 1950s -added to DSM with 5th edition in 2013 -mean age of onset is 12.5 years -Prevalence rates: 2%-4%, equal between girls & boys -most common eating disorder among adolescents -often associated with obesity, no compensatory behaviors • consequences for both physical & psychological health Binge eating disorder (BED) DSM-5-TR criteria for the diagnosis: -episodes of binge eating are defined as consuming an excessive amount of food in a discrete period that is greater than what most people would eat in a similar amount of time and circumstances -during episodes, clients feel they lack control over their behaviors & experience distress -binge eating episodes occur, on average, at least once a week for three months & include 3 or more of the following: • eating more rapidly than normal • eating until feeling uncomfortably full • eating large amounts of food when not feeling physically hungry • eating alone because of embarrassment by the amount of food consumed • feeling disgusted with oneself, depressed, or guilty after overeating -no regular use of inappropriate compensatory behaviors (e.g., purging, fasting, or excessive exercise) as are seen in bulimia nervosa -binge eating does not occur solely with bulimia nervosa or anorexia nervosa Binge eating severity: is ranked based on the number of binge eating episodes that occur in a typical week -Mild: 1 to 3 -Moderate: 4 to 7 -Severe: 8 to 13 -Extreme: 14 or more Pica -persistent ingestion of nonfood items that do not contain nutritional value for at least one month -Commonly ingested substances vary with age and availability • clay, paper, soap, hair, soil, chalk, paint, metal, pebbles, ice. -pediatric pop; predominantly occurs in school-age children • prevalence approx. 5% • often in children who are otherwise developmentally typical -Risk factors: • neglect, lack of supervision, and developmental delay pica DMS-5-TR diagnostic criteria -specify that eating behaviors must not be developmentally appropriate or culturally or socially sanctioned practices -often occurs comorbidly with other medical and mental health conditions • these circumstances, pica must be severe enough to require clinical attention to receive a separate diagnosis -ind 2 eats 1+ nonnutritive, nonfood substances for a month+ and requires medical attention as a result Pica Medical Complications -intestinal obstruction • Consumption of abrasive items such as rocks might cause intestinal obstruction or tear -poisoning • Lead poisoning from excess consumption of paint flakes -medical emergencies -Infections from organisms and parasites that get inside the body from the consumption of dirt or mud -Infections may damage the liver or kidneys -Esophageal tears caused by sharp or harsh objects like metal scraps -Damage to the brain from eating lead or any other harmful substances -Constipation, bloody stool, or diarrhea -Mouth and teeth injuries _________ deficiency anemia and ________ deficiency may cause pica. Iron deficiency anemia and zinc deficiency may cause pica. eating corn starch can cause _________ iron deficiency anemia -secondary to pica (eating corn starch) eating deodorant can cause ________ iron deficiency anemia -has talc in them pagophagia ice eating various forms of pica have been associated with _________ iron deficiency pica is more common among: -rural pregnant African American women -autistic children -institutionalized individuals with intellectual disability Which of the following are the most appropriate management interventions for Aniyah? Select all that apply. collaborate with medical providers to obtain complete blood count (CBC) and zinc levels collaborate with medical providers to obtain lead levels collaborate with medical providers to provide nutritional supplements such as Pediasure recommend that Aniyah's mother remove all pencil erasers from the home begin behavior modification therapy with Aniyah and her mother begin olanzapine 2.5 mg daily collaborate with medical providers to obtain complete blood count (CBC) and zinc levels collaborate with medical providers to obtain lead levels recommend that Aniyah's mother remove all pencil erasers from the home begin behavior modification therapy with Aniyah and her mother Rationale: Initial testing should include a CBC and zinc level. Iron deficiency anemia and zinc deficiency may cause pica. Lead testing is appropriate to ensure that Aniyah has not ingested nonfood items that contain elevated levels of lead; although she admits to eating pencil erasers, she may also consume other nonfood items in the home. Parents should remove the preferred nonfood items from the home, if possible, to help prevent ingestion. Behavior modification therapy using a rewards system is an appropriate treatment method for children with pica. Unless the client presents with nutritional deficits due to pica, nutritional supplements are not indicated. There are currently no medications approved to treat pica. Olanzapine may be prescribed off-label to reduce impulsive eating; however, medications are not considered first-line therapy and p