NR606 / NR 606 Final Exam v2 | Latest 2026/2027 Edition | Diagnosis & Management in PMH II Practicum | Chamberlain | Practice Questions & Accurate Solutions

NR606 / NR 606 Final Exam v2 | Latest 2026/2027 Edition | Diagnosis & Management in PMH II Practicum | Chamberlain | Practice Questions & Accurate Solutions How common is ADHD? Most common neuropsychiatric disorders, affecting approximately 9.4% of children in the U.S. Twice as common in males What are symptoms of hyperactivity and impulsivity in ADHD? Excessive fidgeting or talking, feelings of restlessness and impatience, frequent interruption, and difficultly playing quietly. These symptoms generally occur together and reach their peak severity when the child is around eight years of age. What are inattentive symptoms in ADHD? Difficulty organizing tasks, maintaining a routine, and paying attention to detail. may avoid tasks that are intellectually challenging Symptoms of the inattentive ADHD subtype may not be distinguishable until eight or nine years of age. Define selective attention symptoms in ADHD -Lack of attention to detail -Careless mistakes -Not listening -Losing things -Diverting attention -Forgetfulness Define lack of sustained attention symptoms in ADHD -Poor problem solving -Difficulty completing tasks -Disorganization -Difficulty sustaining mental effort Define impulsivity symptoms in ADHD -Excessive talking -Blurting things out -Not waiting for one's turn -Interrupting Define hyperactivity symptoms in ADHD -Fidgeting -Leaving one's seat -Running, climbing -Trouble playing quietly ADHD in young children often have developmental delays and may engage in behaviors that are less mature than those of their peers ADHD in teens at risk for poor academic performance, problems with driving, difficulties with social situations, risky sexual behavior, and substance abuse As clients reach adolescence, hyperactive symptoms may decline and become less apparent to others, may still struggle with executive function, attention, and working memory ADHD in adults more than 75% of children with ADHD experience symptoms in adulthood may still struggle with executive function, attention, and working memory What is the diagnostic criteria for ADHD? -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 and school). What does the DSM-5 list as symptoms of inattention for ADHD? -Often fails to give close attention to details/makes careless mistakes. -Often has difficulty sustaining attention. -Often does not seem to listen when spoken to directly. -Often does not follow through on instructions/fails to finish tasks. -Often has difficulty organizing tasks and activities. -Often avoids/dislikes tasks that require sustained mental effort. -Often loses things necessary for tasks (e.g., keys, glasses). -Is often easily distracted by extraneous stimuli. -Is often forgetful in daily activities. What does the DSM-5 list as symptoms of hyperactivity and imulsivity for ADHD? -Often fidgets with or taps hands/feet or squirms in seat. -Often leaves seat in situations where remaining seated is expected. -Often runs or climbs inappropriately (in adolescents/adults, may feel restless). -Often unable to play or engage in leisure activities quietly. -Is often "on the go" or acts as if "driven by a motor." -Often talks excessively. -Often blurts out an answer before a question has been completed. -Often has difficulty waiting their turn. -Often interrupts or intrudes on others (e.g., butts into conversations/games) What are common comorbidities with ADHD? learning disabilities, conduct disorders, tics, anxiety, depression, and language disorders; adolescents are at increased risk of substance use disorders Treatment of comorbidities with ADHD Treat ADHD first stimulants are first line What work-up prior to starting stimulants? -EKG if cardiac hx or if hx in first degree relative -Monitor BP, height, and weight -Assess for bipolar, anxiety, Tourette's and SUD as stimulants may exacerbate Things to know when prescribing stimulants -Increased irritability and insomnia can be treated with a low dose of nonstimulant medication which will allow the client to fall asleep. -Abrupt withdrawal after prolonged use can result in irritability and rebound symptoms. -When switching stimulants, discontinue the current medication and start the new medication at a starting dose the next day. Education with stimulants concerning side effects common side effects include restlessness, irritability, anxiety, insomnia, stomachache, headaches, tics, and worsening aggression symptoms Education with stimulants, not including side effects -a worsening of symptoms or "crash" may occur when the medication wears off, especially with immediate-release (IR) medications -take medication with breakfast to decrease anorexia or associated weight loss What are measures to combat anorexia with stimulant medications? Stimulant holidays combined with caloric supplementation and monitoring can help offset stimulant-related weight loss Focalin has less of this effect What nonpharmacological interventions can schools implement for ADHD? Schools can provide educational support, behavioral interventions in the classroom, and accommodations, which can help children achieve academic success. What does the APP recommend as first line treatment for ADHD under the age of 6? parent training in behavior management as a first-line intervention What do parents learn when trained in behavior therapy? -Positive Communication -Positive Reinforcement -Structure and Discipline How does training parents in behavior therapy help those with ADHD? Behavior therapy, given by parents, teaches children to better control their own behavior, leading to improved functioning at school home and in relationships. Learning and practicing behavior therapy requires time and effort, but has lasting benefits for the child. What psychotherapy for older kids and adolescents along with medications for ADHD? cognitive-behavioral therapy (CBT), social and organizational skill training, and family therapy. What is key to effective ADHD treatment (1) start with low initial doses of stimulants (2) carefully titrate the dose up to adequate levels; (3) dose three times a day initially (immediate release), then move to once or twice a day once an optimal dose is determined (4) monitor for side effects; and (5) provide close follow-up. Parent Training programs for ADHD and ODD teach what? -Positive reinforcement (e.g., token systems, praise) -Consistent consequences (e.g., time-outs, loss of privileges) -Clear rules and expectations -Ignoring minor misbehaviors -Enhancing parent-child relationships -Emotion regulation and communication skills What is the DSM5 criteria for ODD? o symptoms must have occurred during an interaction with one or more individuals that are not siblings within the last 6 months o 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. o Presentation includes: Angry/Irritable Mood, -Loss of temper -Easily annoyed -Anger and resentment 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 Child can't meet criteria for DMDD What is the hallmark characteristic of ODD? include persistent angry and irritable mood, argumentative and defiant behavior, and vindictiveness Severity rating with ODD DSM5 diagnosis Mild- one setting Moderate- two settings Severe- three or more settings What do ODD symptom expression have in all cases? In all cases, symptom expression impairs the social functioning of the individual and is more evident in interactions with peers or adults whom the individual knows. What is commonly comorbid with ODD? ADHD and often proceeds conduct disorder, high co-occurrence with anxiety and MDD, associated with increased risk of suicide ideation What is conduct disorder characterized by? severe behaviors that violate societal norms or the rights of others and may involve aggression towards others, animals, theft, and/or the destruction of property Correlation between ODD and conduct disorder children and youth with ODD may later meet diagnostic criteria for conduct disorder; however, most children with ODD do not develop conduct disorder. What are individuals with conduct disorder at risk for? -criminal behaviors and substance-related disorders -also at risk for mood and anxiety disorders, impulse-control disorders, psychotic disorders, and posttraumatic stress disorder What are temperamental risk factors for conduct disorder? Difficult infant temperament and lower-than-average intelligence What is the most important point with conduct disorder? outward signs of aggression, antisocial behavior, and disregard for social rules that characterize it are often seen in the context of other primary psychiatric disorders. What are environmental family level risk factors for conduct disorder? caregiver abuse and neglect, varying caregivers or child-rearing practices, harsh discipline, family criminality, or substance-related disorders What are environmental community level risk factors for conduct disorder? rejection by peers, participation in a delinquent peer group, poverty, and exposure to violence What are genetic or physiological risk factors for conduct disorder? Family members with conduct disorder, depressive and bipolar disorders, schizophrenia, ADHD, or substance use disorders DSM5 criteria for conduct disorder At least 3 of the following 15 criteria must be present in the past 12 months, with at least 1 in the past 6 months, from any of these categories: Aggression to People and Animals -Often bullies, threatens, or intimidates others -Often initiates physical fights -Has used a weapon that can cause serious physical harm -Has been physically cruel to people -Has been physically cruel to animals -Has stolen while confronting a victim -Has forced someone into sexual activity Destruction of Property -Has deliberately engaged in fire setting with the intention of causing serious damage -Has deliberately destroyed others' property (other than by fire setting) Deceitfulness or Theft -Has broken into someone else's house, building, or car -Often lies to obtain goods or favors or to avoid obligations (i.e., "cons" others) -Has stolen items of nontrivial value without confronting a victim (e.g., shoplifting, forgery) Serious Violations of Rules -Often stays out at night despite parental prohibitions, beginning before age 13 -Has run away from home overnight at least twice while living in parental or parental surrogate home (or once without returning for a lengthy period) -Is often truant from school, beginning before age 13 If 18 or older does not meet criteria for antisocial personality disorder Specific things conduct disorder exhibits empathy, aggression, and impulsivity DSM5 for intermittent explosive disorder o Low tolerance for frustration and adversity o Frequent impulsive or angry outbursts that often include temper tantrums o Verbal assaults, or physical assaults towards others, animals, or property o Outbursts are unplanned, have a rapid onset, are out of proportion to the trigger that elicited the response, and lasts no longer than 30 minutes o Verbal outbursts occur on an average of twice a week for three months What does management for disruptive disorders focus on? -reducing positive reinforcement for undesirable behaviors -encouraging prosocial behaviors -using nonviolent forms of discipline -following consistent parenting strategies Treatment for disruptive disorders may include one or more of the following interventions based on the unique needs of the individual and family -Group parent-caregiver training programs -Individual parent-caregiver training -Group child-focused programs -Cognitive problem-solving skills training -School-based programs -Medication Tell me about Group parent-caregiver training programs in treatment of disruptive disorders Recommended for children aged 3-11 years and their families. Provides psychoeducation about the disorder and support for caregivers. Tell me about Individual parent-caregiver training in treatment of disruptive disorders Recommended when a child's behavior is extreme or complex and requires individualized attention to meet the family's unique circumstances. Tell me about Group child-focused programs in treatment of disruptive disorders Recommended for children aged 9-14 years to enhance social and problem-solving skills Tell me about Cognitive problem-solving skills training in treatment of disruptive disorders Recommended for children to help them see situations differently and respond appropriately Tell me about School-based programs in treatment of disruptive disorders Recommended for children and adolescents to help them relate to peers and improve school performance. Tell me about medication in treatment of disruptive disorders Currently, there is no FDA-approved treatment for disruptive disorders; however, pharmacologic management can help reduce symptom burden, especially in children with comorbid conditions such as attention-deficit/hyperactivity disorder (ADHD). In situations that involve non-amenable aggression, providers may choose to prescribe mood stabilizers, antidepressants, or atypical antipsychotics Facial features of FAS o Skin folds at the corner of the eye o Small head circumference o Low nasal bridge o Small eye opening o Short nose o Small midface o Indistinct philtrum o Thin upper lip Cognitive issues with FASD -Problems with memory and learning, especially math -Poor reasoning and limited executive function -Problems with attention -Intellectual disability Physical issues with FASD -Prenatal growth deficits -Poor motor skills and coordination -Vision and hearing problems -Problems with heart, bones, kidneys -Short stature and low body weight -Small head size Abnormal facial features Behavioral issues with FASD -Poor social skills -Poor emotional control -Impulsivity -Hyperactivity Functional issues with FASD -Difficulties with sleep and feeding in infancy -Difficulties with self-care The Institute of Medicine of the National Academies (IOM) defines what four diagnostic categories for FASD -Fetal alcohol syndrome (FAS) -Partial FAS (pFAS) -Alcohol-related neurodevelopmental disorder (ARND) -Alcohol-related birth defects (ARBD Who should be on the collaboration team for FASD? primary care provider, developmental pediatrician, geneticist, psychologist, social worker, speech-language pathologist, occupational therapist, or educational specialist What provides the best prognosis for FASD? Prognosis is best if children receive a diagnosis and begin treatment before the age of six What can early intervention for FASD do? Early intervention services can help children develop basic skills such as walking, talking, and interacting with others What pharmacological treatment for FASD? -SSRI -Antidepressants -Alpha 2 agonists -Anticonvulsants -Stimulants -Atypical antipsychotics Complementary and alternative therapies for FASD -Relaxation therapy -Meditation -Art therapy -Yoga and exercise -Acupuncture and acupressure -Massage, Reiki, and energy work -Vitamins and herbal supplements -Animal-assisted therapy Define the Individuals with Disabilities Education Act (IDEA) Passed in 1975, is the federal law designed to ensure that children who have disabilities receive free appropriate public education What does the IDEA act ensure? -Children with an identified disability receive individualized special education and services that address their needs. -Children with disabilities receive preparation for employment and independent living. -Children and families impacted by disability are protected under the law. -Federal agencies, states, localities, and educational service agencies that provide educational assistance to children with disabilities receive support. What does Section 504 of the Rehabilitation Act of 1973 protect? the rights of individuals with disabilities who are enrolled in programs receiving federal financial assistance through the U.S. Department of Education Individualized Education Plans (IEP) or 504 plans, which describe the services and accommodations that will be provided to students with qualifying disabilities. PMHNP role in identifying early with diagnosis for Disabilities Education Act -PMHNPs may be instrumental in identifying diagnoses that qualify children for services -PMHNPs can provide education to parents about their rights under the law, provide documentation to support the creation of IEPs or 504 plans, and advocate for services for children -PMHNPs may also work directly with teachers and school personnel to identify strategies to help children function in the educational setting. What disorders does the MIDI screen for? Gambling, trichotillomania, kleptomania, pyromania, intermittent explosive disorder, compulsive buying, compulsive sexual behavior . How are MIDI items scored? Each uses a 0-4 scale, with totals per disorder indicating symptom severity . What behaviors are assessed for pathological gambling in the MIDI? Persistent, recurrent gambling behavior leading to significant distress or impairment, such as lying about gambling, financial problems, or failed attempts to stop. How should high scores on the gambling section of the MIDI be interpreted? High scores suggest possible Gambling Disorder, especially if criteria like tolerance, preoccupation, and chasing losses are endorsed. What symptoms suggest IED in the MIDI? Recurrent episodes of impulsive aggression (verbal or physical) that are out of proportion to any provocation What do elevated scores on the IED section indicate? Scores suggest impaired impulse control around anger, potentially meeting criteria for Intermittent Explosive Disorder, especially if episodes are frequent and cause distress or impairment. What is assessed in the kleptomania section? Recurrent failure to resist urges to steal items not needed for personal use or value. What does a positive endorsement in kleptomania section mean? Suggests potential Kleptomania if stealing is impulsive, tension is felt before, and relief occurs after. What signs indicate pyromania? Repeated deliberate fire setting with emotional arousal before and gratification afterward—not done for monetary gain, revenge, or ideology. How should pyromania section be interpreted? Indicates potential Pyromania when fire-setting is impulsive and emotionally driven, and not better explained by another disorder. What behaviors are probed in trichotillomania MIDI category? Recurrent hair pulling leading to hair loss, often with failed attempts to stop and associated emotional relief. What does a high score in trichomania indicate? Suggests Trichotillomania, especially if behavior is distressing or impairing and not attributable to dermatologic conditions. What defines compulsive buying behavior in the MIDI? Excessive, uncontrollable shopping or spending that causes distress, debt, or interpersonal problems. How should elevated responses on compulsive buying section be interpreted? Could reflect Compulsive Buying Disorder, even though it's not a formal DSM-5 diagnosis—often comorbid with mood or anxiety disorders. MIDI compulsive sexual behavior category Recurrent, excessive sexual fantasies or behaviors that the person feels unable to control and which cause distress or harm. Interpretation of high scores in compulsive sexual section? Indicates Compulsive Sexual Behavior Disorder (ICD-11), though not in DSM-5; may co occur with impulse control, trauma, or mood disorders. General interpretation of the MIDI 0-1 = Minimal or no evidence 2-3 = Possible subclinical presentation 4+ = Strong indication of diagnostic criteria being met How are ADLs impaired in FAS? -Personal hygiene: May require reminders, supervision, or hands-on assistance. -Dressing: Poor motor planning and impulse control may cause resistance or inappropriate choices. -Feeding/eating: May have oral-motor issues, poor table manners, or dietary impulsivity. -Toileting: Potty training often delayed; accidents may occur into later childhood. -Grooming: Difficulty with hair brushing, teeth brushing, or bathing independently. How are IADLs affected in FAS? -Meal preparation: Difficulty sequencing tasks, unsafe tool use (knives, stove). -Money management: Impaired judgment, impulsivity, and inability to understand value or budgeting. -Medication management: Poor memory and planning can lead to missed doses or overdosing. -Transportation: Unsafe crossing streets, trouble navigating routes or schedules. How is school and learning affected in FAS? -Executive functioning deficits: Trouble with planning, organizing, and completing tasks. -Attention issues: Often co-occurs with ADHD. -Learning disabilities: Difficulty with math, reading comprehension, abstract thinking. -Behavioral problems: Noncompliance, aggression, or social inappropriateness How is social and emotional functioning affected in FAS? -Poor social skills: Difficulty reading social cues, forming and maintaining friendships. -Impulsivity and disinhibition: May result in risky behaviors or inappropriate interactions. -Low frustration tolerance: Frequent emotional outbursts or meltdowns. How is vocational/independent living affected in FAS? -Poor judgment and decision-making: Challenges with safety, work reliability, and time management. -Dependence on caregivers: Most individuals with FAS need lifelong support or structured environments. Tell me about structured behavior management programs for the treatment of FAS -Use of positive reinforcement: Praise, tokens, or tangible rewards for appropriate behaviors. -Clear and consistent routines: Predictability helps reduce anxiety and improve behavior. -Visual schedules and cues: Visual supports assist with transitions and task completion. -Time-outs and calm-down spaces: Used to teach self-regulation, not as punishment. Tell me about parent/caregiver training in the treatment of FAS -Behavioral Parent Training (BPT): Teaches skills for managing defiance, inattention, and tantrums (e.g., PCIT, Triple P, Incredible Years). -FASD-specific parent programs: Emphasize understanding brain-based behavior, e.g., Families Moving Forward (FMF) program. -Focus on consistency, not punishment: Traditional discipline may not be effective due to cognitive limitations. Tell me about CBT in treating FAS While CBT may be helpful, it must be adapted for: Concrete learners Shorter attention spans Visual aids and repetition Can target emotion regulation, anxiety, and social problem-solving. Tell me about social skills training in the treatment of FAS Group or one-on-one formats to teach: Taking turns Reading facial expressions Maintaining conversations Tell me about self-regulation strategies in the treatment of FAS Zones of Regulation Alert Program ("How Does Your Engine Run?") Mindfulness techniques with visual supports Use of fidget tools, weighted blankets, or calm corners Risk factors for eating disorders? -Cultural norms that idealize a thin appearance -Having a close relative with an eating disorder -Weight stigma in the culture -Trauma -Intense family expectations related to physical appearance -History of being bullied about weight or physical appearance Percentage of people affected by eating disorders 9% How deadly are eating disorders? second after opioid overdose What are common characteristics of individuals with eating disorders? -Perfectionism -Low self esteem Define anorexia nervosa an eating disorder characterized by restrictive eating patterns, extremely low body weight, and an intense fear of gaining weight. Individuals with anorexia nervosa may also engage in excessive exercise What percent of population has Anorexia? 1% (0.3% of adolescents DSM-5 for anorexia nervosa -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 Mild anorexia BMI Less than or equal to 17 Moderate anorexia BMI 16-16.99 Severe anorexia BMI 15-15.99 Extreme anorexia BMI Less than 15 Cardiovascular structural changes with anorexia Decreased cardiac mass, reduced cardiac chamber volume, mitral valve prolapse, myocardial fibrosis. Pericardial effusion has been reported. This generally occurs with weight restoration. Cardiovascular functional changes with anorexia Bradycardia, hypotension, decreased diastolic ventricular function, diminished heart rate variability, QT interval prolongation. Other electrocardiogram abnormalities can be seen as electrolytes impact the conductivity of the myocardium. Gynecologic and reproductive with anorexia Secondary amenorrhea is common due to disruption of hormones, including gonadotropin releasing hormone and luteinizing hormone. Decreased libido is a side effect of hormonal imbalances related to anorexia. Greater incidence of pregnancy complications including miscarriages, premature birth, small head circumference, and low birth weight infants. Endocrine with anorexia Multiple endocrine complications, including hypothalamic-pituitary abnormalities that contribute to severe bone loss. GI with anorexia Gastroparesis, diarrhea or constipation, elevated liver function tests, superior mesenteric artery syndrome, acute pancreatitis, gastroesophageal reflux disease, and dysphagia can all occur as a result of anorexia. Renal/electrolytes with anorexia Decreased glomerular filtration rates and difficulty creating concentrated urine can lead to diuresis, hyponatremia, and dehydration. Clients who have restricting type anorexia can present with a low creatinine. cc Pulmonary with anorexia Weakness and wasting of respiratory muscles can lead to dyspnea, reduced aerobic capacity, and decreased pulmonary capacity. Clients with purging type anorexia and aspirate regurgitated food and develop pneumonia. Hematologic with anorexia Cytopenia and bone marrow changes are common. Petechiae and purpura may be seen on extremities. Neurologic with anorexia Neurological conditions including Wernicke encephalopathy, Korsakoff syndrome, brain atrophy, and other brain structure changes can be seen. Dermatologic with anorexia -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 Treatment goals for anorexia -restoration of sufficient nutrition -return to a healthy weight -reduction of excessive exercise -elimination of binge-purge and binge-eating behaviors. What is essential to anorexia recovery? Psychotherapy: family therapy and cognitive behavior therapy Pharmacological treatment of anorexia Medications can also help address comorbid psychopathologies such as depressive disorders, anxiety disorders, and obsessive-compulsive disorders What is bulimia characterized by 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 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 Lifetime prevalence rate with bulimia 1.5% DSM-5 for bulimia -recurrent incidents of binge eating are 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 a 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 and weight unduly influence self-evaluation -disturbance does not occur exclusively during episodes of anorexia nervosa. Dental with bulimia -Enamel erosion -Hot/cold sensitivity -Discoloration -Dental caries -Gum disease Endocrine with bulimia -Menstrual irregularities -Osteopenia and osteoporosis -Diabetes GI with bulimia -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 with bulimia -Dehydration -Hypokalemia -Hypochloremia -Hyponatremia -Metabolic alkalosis -Hypomagnesemia -Hypophosphatemia What is the hallmark feature of binge eating disorder? episodes of the consumption of an excessively large amount of food accompanied by a sense of loss of control over the experience along with distress or secrecy about eating or eating when not hungry. What are the prevalence rates of BED? 2-4% Most common eating disorder among adolescents DSM-5 for BED -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 and experience distress -binge eating episodes occur, on average, at least once a week for three months and include three 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 How is binge eating severity 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 Treatment of bulimia and BED Treatment of bulimia and binge eating disorder may be approached by combining antidepressant medications with psychotherapy What medication should be avoided in active bulimia? Bupropion should be avoided due to the risk of seizures in clients with active symptoms of bulimia nervosa What is FDA approved for BED? Lisdexamfetamine has been approved for moderate to severe BED in adults; no medications are currently FDA approved for children or adolescents with BED 1st line med for bulimia fluoxetine 2nd line med for bulimia sertraline escitalopram fluvoxamine 3rd line med for bulimia tricyclic antidepressants trazodone MAOIs topiramate CBT phases in treatment of bulimia and BED -psychoeducation about weight and adverse effects of bingeing and purging; -reducing shape and weight concerns and dieting behaviors; -maintenance planning and relapse prevention Brief strategic therapy for bulimia and BED focuses on disrupting dysfunctional responses rather than identifying the causes of the problem, may be effective, especially for clients with comorbid mental health diagnoses How is Pica characterized? persistent ingestion of nonfood items that do not contain nutritional value for at least one month What are commonly ingested substances with Pica? vary with age and availability and range from clay, paper, soap, hair, and soil to chalk, paint, metal, pebbles, or ice Prevalence rate of Pica 5% mostly school aged children What are risk factor for Pica neglect, lack of supervision, and developmental delay DSM-5 for Pica -eating behaviors must not be developmentally appropriate or culturally or socially sanctioned practices -must be severe enough to require clinical attention to receive a separate diagnosis Medical complications of Pica -Lead poisoning from excess consumption of paint flakes -Consumption of abrasive items such as rocks might cause intestinal obstruction or tear -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 Treatment of Pica -Initial testing CBC, zinc level, lead -Remove preferred food items from home -Behavior modification therapy using a rewards system 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 What is ARFID characterized by? characterized by a reduced intake of food volume or variety due to fear of aversive consequences of eating, a lack of interest in food or eating, or sensory sensitivity to food Children with ARFID typically eat only a few preferred food items that often do not meet their nutritional needs. These eating habits differ from the food refusal behaviors seen in typical childhood development Children with ARFID have habitual food avoidance which affects their weight and nutritional health Who has an increased risk for ARFID? -Children with OCD, ASD, ADHD, MRDD -presence of a maternal eating disorder or a client's history of gastroesophageal reflux disease, vomiting, and other medical problems may also increase risk. DSM-5 ARFID -an eating or feeding disturbance that is not due to a food shortage or cultural practice and is associated with one or more of the following: significant weight loss significant nutritional deficiency dependence on enteral feeding or oral nutritional supplements impaired psychosocial functioning -does not occur exclusively during the course of anorexia nervosa or bulimia nervosa, and is not attributable to a concurrent medical condition or mental disorder. Treatment of ARFID -no medication is specifically indicated for use in this disorder -Once clients with ARFID are medically stable, family-based therapy adapted specifically for clients with ARFID has demonstrated effectiveness What are the questions in the SCOFF tool? -Do you make yourself Sick because you feel uncomfortably full? -Do you worry you have lost Control over how much you eat? -Have you recently lost more than One stone (14 pounds or 6.35 kg) in three months? -Do you believe yourself to be Fat when others say you are too thin? -Would you say that Food dominates your life? What does the acronym SCOFF stand for in the SCOFF screening tool? Sick, Control, One stone, Fat, Food How is the SCOFF tool scored? One point for each "yes" answer. A score of 2 or more suggests a likely case of an eating disorder and warrants further evaluation. What is the maximum possible score on the SCOFF questionnaire? 5 points (1 point per item, 5 items total). Define gender identity One's concept of oneself as male, female, a blend of both, or neither derived from an interaction of biological traits, developmental influences, and environmental conditions. Transgender Nonbinary Cisgender Agender Define gender expression The external appearance or performance of one's gender. Expression may include clothing, behavior, or other characteristics. Expression may be associated with masculine traits, feminine traits, both, or neither and may or may not conform to socially defined gender behaviors. Gender expression does not necessarily reflect gender identity. Feminine Masculine Androgynous Gender-neutral Gender non-conforming Define sexual orientation Enduring emotional, romantic, or sexual attraction to others. Heterosexual/straight Homosexual/gay/lesbian Bisexual Pansexual Asexual Define assigned sex Sex assigned to an infant at birth, based on visible sex organs and other physical characteristics. Male Female Intersex When do children notice and understand gender Children begin to become aware of the physical differences between boys and girls at approximately 2 years of age. By 4 years of age, most children have an established gender identity DSM-5 gender dysphoria A marked incongruence between one's experienced/expressed gender and assigned gender, lasting at least 6 months, as manifested by at least six of the following (one of which must be Criterion A1): 1. A strong desire to be of the other gender or an insistence that one is the other gender. 2. A strong preference for wearing clothes typical of the opposite gender. 3. A strong preference for cross-gender roles in make-believe play or fantasy play. 4. A strong preference for the toys, games, or activities stereotypically used or engaged in by the other gender. 5. A strong preference for playmates of the other gender. 6. A strong rejection of toys, games, and activities typical of their assigned gender. 7. A strong dislike of one's sexual anatomy. 8. A strong desire for the primary and/or secondary sex characteristics that match one's experienced gender. The condition is associated with clinically significant distress or impairment in social, school, or other important areas of functioning. Treatment of gender dysphoria -Social affirmation -Legal affirmation -Medical affirmation -Surgical affirmation Define social affirmation in GD treatment Pronouns and gender expression (hairstyles, clothing) Define legal affirmation in GD treatment Legally changing name and gender on identification Define medical affirmation in GD treatment Pubertal suppression and gender-affirming hormone supplementation Define surgical affirmation in GD treatment Mastectomy or breast augmentation ("top" surgery), genital gender confirmation surgery ("bottom" surgery) Family therapy for GD? -A supportive family increases resilience for the client, while a family that is resistant or discriminative can cause significant distress -integral part of the coming out process for clients as they learn to navigate new roles within their family environment SUD by time individuals reach adulthood Nearly half will have tried an illicit substance, while over 80% will have used alcohol alcohol, Tabacco, and marijuana are most used Grade 8, 10, 12 alcohol use 38.3% Grade 8, 10, 12 marijuana use 24.6% Grade 8, 10, 12 vape/cigarette use 27.1% Grade 8, 10, 12 illicit drugs other than marijuana use 9.2% Common comorbidities with SUD 60% meet criteria for: Anxiety disorders Depression Bipolar disorder Psychotic illness Borderline personality disorder Antisocial personality disorder Questions in the CRAFFT tool C: Have you ever ridden in a car driven by someone, including yourself, who was "high" or had been using alcohol or drugs R: Do you ever use alcohol or drugs to relax, feel better about yourself or fit in? A: Do you ever use alcohol or drugs while you are by yourself (Alone)? F: Do you ever forget things that you did while using alcohol or drugs? F: Do your family or friends ever tell you that you should cut down on your drinking or drug use? T: Have you ever gotten into trouble while you were using alcohol or drugs? Two or more "yes" answers suggest a significant problem. Drug testing adolescents The AAP supports the use of drug testing in emergencies, on a voluntary basis as part of a full assessment of behavioral or mental health symptoms, and as part of therapy or monitoring of a client with an identified substance use disorder; the use of "suspicionless" drug testing as a means of screening for drug use is not useful for both practical and ethical reasons. Treatment adolescent SUD -Behavioral treatments are the most prevalent interventions for adolescent clients with substance use disorders. -Common types of therapy include cognitive behavioral therapy, group therapy, contingency management, and motivational interviewing -Adolescents may also benefit from participation in 12-step programs or peer-to-peer programs. -Residential treatment may be indicated for clients who require stabilization, present a danger to themselves or their families, or present a public safety risk Family therapy SUD Research indicates that Multidimensional Family Therapy may be an alternative to residential treatment in adolescents with substance use and co-occurring mental health disorders MAT adolescent SUD Medication-assisted treatment (MAT) is less likely to be used with adolescent clients. Define tolerance With repeated ingestion of a drug, the drug shows decreased effect. Increasing doses are required to achieve the effects noted with the original administration. Define dependance State of adaptation produced with repeated administration of certain drugs so that physical symptoms occur when the drug is discontinued abruptly. Define addiction 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. Define withdrawal Physiological and psychological reactions that occur when the use of a substance is stopped abruptly. Define intoxication Condition following the ingestion of a substance resulting in changes in level of consciousness, cognition, perception, judgment, and behavior. How many adults have experienced four or more ACEs? 1 in 6 How many of the top ten leading causes of death are related to ACEs? 5 or more What does the ACE pyramid show? From bottom to top the pyramid shows the mechanisms by which ACEs influence health and well-being from conception to death. What is the ACE pyramid from bottom to top? -Generational embodiment / Historical trauma -Social conditions / Local context -ACEs -Disrupted neurodevelopment -Social, emotional, and cognitive impairment -Adoption of health risk behavior -Disease, disability, and social problems -Early death What are individual risk factors for ACEs? -A lack of closeness to parents/caregivers -Early sexual activity -Few or no friends -Friends who engage in aggressive or delinquent behavior What are family risk factors for ACEs? -Caregiving challenges related to children with disabilities, mental health issues, or chronic physical illnesses -A limited understanding of children's needs or development -Caregivers who were abused or neglected as children -Young caregivers or single parents -Low income or low levels of education -High levels of parenting stress or economic stress -Isolation -High conflict and negative communication styles -Attitudes accepting of or justifying violence or aggression What are community risk factors for ACEs? -High rates of violence and crime -High rates of poverty and limited educational and economic opportunities -High unemployment rates -Easy access to drugs and alcohol -Few community activities for young people -Unstable housing and where residents move frequently -Food insecurity What are the groups of ACEs? Abuse Neglect Household instability Cultural challenges Racism and structural racism Tell me about ACE intimate partner violence occurs when an individual purposely harms or threatens to harm a current or past partner or spouse. IPV may involve controlling or coercive behavior or physical, sexual, verbal, financial, or emotional abuse. It may also include stalking, terrorizing, blame, humiliation, manipulation, or intentional isolation from family and friends Tell me about children and intimate partner violence Children may witness IPV or be directly injured. Children exposed to IPV are also more likely to experience emotional or physical abuse, neglect, and community violence and often experience short- and long-term emotional, physical, psychological, and behavioral effects Tell me about ACE as a psychological maltreatment -involves the failure of a parent or caregiver to meet a child's psychological or emotional needs. -PM is embedded in all other forms of child maltreatment How is a child affected by psychological maltreatment -PM directly attacks a child's sense of self, and is demeaning or humiliating, involving acts of commission, such as verbal attacks, or acts of omission, such as emotional unresponsiveness by a caregiver. -increases a child's vulnerability to depression and produces psychological trauma. Tell me about physical abuse as an ACE -occurs when a parent or caregiver commits an act that causes physical injury to a child How are children affected by physical abuse may struggle with self-esteem or social relationships and may have trouble trusting authority figures. Some children develop stress reactions. They may act out, become aggressive or develop behavior problems, while others may become anxious, numb, or withdrawn. Some children lose typical fight-or-flight reactions, making them more susceptible to danger. Tell me about sexual abuse and sexual violence with ACE involves any interaction between a child and an adult or another child in which the child is used for the sexual gratification of the perpetrator or an observer may involve touching or non-touching What affects does sexual abuse have on the child can have long-term consequences for physical and mental health, including increased risk for substance abuse, engagement in risky sexual behaviors, self-cutting or suicidal behavior, post-traumatic stress syndrome, depression, and anxiety Statistics with ACE -Physical abuse is 10% of maltreatment cases -Sexual abuse is 7% of maltreatment cases -Neglect is 60% of maltreatment cases Tell me about neglect as an ACE occurs when a parent or caregiver fails to provide for a child's age-appropriate needs, such as food, shelter, clothing, education, medical care, supervision, or emotional needs. How are children affected by neglect? Children who have experienced neglect may present with poor hygiene, inadequate weight gain, or clothing that fits poorly or is inappropriate for the weather. Neglect can disrupt healthy development and lead to lifelong consequences. What can cause family instability as an ACE may be caused by factors such as parental mental illness, stress, substance abuse, or suicide. Also the presence of violence toward the mother in the family How are children affected by family instability Children exposed to family instability may struggle socially, cognitively, or behaviorally. Tell me about loss as an ACE experience instability from the loss of a parent or caregiver due to death, divorce, abandonment, or incarceration. Tell me about community violence as an ACE involves the exposure of a child to acts of interpersonal violence in a public setting by individuals not intimately connected to the child Tell me about bullying as an ACE a form of aggression or harassment that inflicts social, emotional, physical, or psychological harm on someone a perpetrator perceives to be less powerful, can be verbal, physical, or social What are the effects of bullying -Stress, anxiety, or depression -Traumatic stress reactions -Anger or frustration -Isolation or loneliness -Poor self-esteem or self-image -School avoidance or poor school performance -Separation anxiety -Health complaints -Self-injury -Eating disorders -Suicidal or homicidal ideations or actions Tell me about racism and structural racism as an ACE a system of assigning value and providing opportunity based on physical properties such as skin color ACE effects on health obesity, diabetes, depression, suicide attempts, STDs, heart disease, cancer, stroke, COPD, broken bones ACE effects on behavior smoking, alcoholism, drug use ACE effects on life potential graduation rates, academic achievement, lost time from work As ACEs increases so does...? the risk for negative health and well-being outcomes What are the three parts of psyche by Terry Real that help clients understand the aftereffects of trauma and to help them relate to others from their most thoughtful, mature self. Wounded child Adaptive child Functional adult Tell me about the wounded child Was wounded by abuse or neglect -A young, vulnerable, possibly pre-verbal child -Often overwhelmed, yet longs for connection -Much trauma work focuses on the wounded child -But it's NOT usually the wounded child that brings dysfunction into adult relationships Tell me about the adaptive child A child's version of an adult that developed to protect the wounded child -Often a perfectionist, harsh and unforgiving -Sees the world in black and white -An older child -Unable to learn skills -Cares only about self-preservation -Views intimacy as a threat -Not only reacts to aggressor, but also identifies with aggressor Tell me about the functional adult Makes thoughtful decisions -Mature, thoughtful, nuanced, forgiving -Based in the present -Understands imperfection and ambiguity -Makes sense of trauma and its impact on relationships -Adaptable - unlike the child parts, the functional adult can learn and use new skills According to Terry Real who causes problems in current relationships it's usually the adaptive child What factors promote resilience? -Close relationships with skilled caregivers or other caring adults -Caregiver knowledge and use of positive parenting skills -Having a sense of purpose (faith, culture, identity) -Individual competencies (problem-solving skills, self-regulation, autonomy) -Opportunities to connect socially -Access to support services for parents and families -Community support resources What are the six principles of trauma informed care? -Safety -Trust & Transparency -Peer support -Collaboration -Empowerment & choice -Cultural, Historical, and Gender Awareness Tell me about safety Safety is the most fundamental principle to avoiding retraumatization. Creating a physical setting and client-provider interactions that generate physical and psychological safety are foundational to providing trauma-informed care. Tell me about trust and transparency Establishing a trusting relationship or therapeutic alliance is critical to the trauma informed approach. Trust may be established through engagement in kind, respectful interactions, empowering intake procedures, and transparency in discussions of treatment goals and modalities appropriate to the client's developmental level. Tell me about peer support Providing opportunities for connecting with other trauma survivors may help to establish safety, foster hope, and promote healing through shared experience. Tell me about collaboration Empowering the client to play an active role in decisions about their treatment, when developmentally appropriate, fosters a sense of responsibility and helps to balance the level of power between the provider and client. Tell me about empowerment and choice Listening to and acknowledging the client will help them find their voice and give them a sense of control over their story. Prioritizing choice empowers clients to be partners in their care, which can promote self-efficacy, agency, and dignity. Tell me about cultural, historical, and gender awareness Trauma-informed care acknowledges that some trauma may be a result of a client's culture, historical events such as war or conflict, or being a part of a marginalized or minority group. Sensitivity to a client's cultural, historical, or gender identity is important to ensuring their comfort and safety during treatment. How many adolescents experience PTSD between 3.6-5% What places youth at risk for PTSD -Prior trauma -Adverse childhood experiences -Personal or family history of psychiatric disorders -Female gender -Severe trauma exposure What are consequences of PTSD? -social, occupational, and physical impairment, physical health problems, reduced quality of life, and increased risk of suicide -more likely to present with comorbidities including major depressive disorder, anxiety disorder, and substance use disorder When does PTSD occur? after exposure to actual or threatened death, serious injury, or sexual violence. The client may have experienced the event personally or may have been a witness to the event. The client may also have learned of a violent or accidental death of a loved one In PTSD what can the source of trauma not be from exposure must not be through media, including movies, television, or the internet. Length of time and symptoms with PTSD Symptoms typically begin within the first 3 months after the traumatic event occurred, and the client must have symptoms for at least 1 month to be diagnosed Intrusion symptoms in PTSD -Recurrent, intrusive memories of the trauma; children may engage in repetitive play expressing themes of the trauma. -Distressing dreams or nightmares -Dissociative reactions, or flashbacks -Intense psychological distress or physiological reactions when exposed to cues that symbolize or represent an aspect of the trauma Avoidance symptoms of PTSD -Avoidance of distressing memories, thoughts, or feelings -Avoidance of reminders, including people, places, situations, of the traumatic event Negative cognitive or mood symptoms with PTSD -Memory deficits surrounding the traumatic event -Exaggerated negative beliefs of self or environment -Distorted cognitions and self-blaming behaviors related to the cause or consequences of trauma -Persistent negative emotions, including anger, guilt, fear, or shame -Feelings of detachment from others -Persistent inability to experience positive emotions -Social withdrawal in children under the age of 6 Arousal or reactivity symptoms with PTSD -Irritability and verbal or physical aggression -Reckless or risk-taking behaviors -Hypervigilance -Concentration difficulty -Exaggerated startle response -Sleep disturbances Treatment for PTSD Irritability and verbal or physical aggression Reckless or risk-taking behaviors Hypervigilance Concentration difficulty Exaggerated startle response Sleep disturbances Parental involvement is important to help establish family resilience DSM-5 PTSD children and adolescents Exposure to actual or threatened death, serious injury, or sexual violence in one or more of the following ways: -Directly experiencing the traumatic event(s). -Witnessing, in person, the event(s) as it occurred to others, especially primary caregivers. -Learning that the traumatic event(s) occurred to a parent or caregiving figure. Presence of one or more intrusion symptoms: -Recurrent, involuntary, intrusive distressing memories of the event(s). Note: In young children, this may be expressed through play. -Recurrent distressing dreams related to the trauma. -Dissociative reactions (e.g., flashbacks). -Intense distress at exposure to cues resembling the trauma. -Marked physiological reactions to reminders of the trauma. One (or more) of the following either: (1) Persistent avoidance of stimuli or (2) Negative alterations in cognitions: -Avoidance of activities, places, or people that are reminders. -Avoidance of talking or thinking about the trauma. -Increased negative emotional states (e.g., fear, guilt, sadness). -Diminished interest in play or social interaction. -Social withdrawal. -Reduction in expression of positive emotions. Time frame with acute stress disorder symptoms that last from three days to 1 month immediately following exposure to the traumatic event What can clients experience with acute stress disorder? catastrophic thoughts, panic attacks, and guilt related to the event What do young children experience with acute stress disorder? may present with symptoms of separation anxiety. Post-concussive symptoms, including headaches, sensitivity to light, difficulty concentrating, irritability, and dizziness, are common, even though a head injury may not have occurred Who is the incidence of acute stress disorder higher in? higher in clients who experienced interpersonal trauma, such as assault or rape, compared to those who experienced traumatic motor vehicle or industrial accidents DSM5 acute stress disorder in children and adolescents Exposure to actual or threatened death, serious injury, or sexual violence in one or more of the following ways: -Directly experiencing the traumatic event(s). -Witnessing, in person, the event(s) as it occurred to others, especially primary caregivers. -Learning that the traumatic event(s) occurred to a parent or caregiving figure. Presence of 9 (or more) symptoms from any of the 5 categories below, beginning or worsening after the trauma. 1. Intrusion Symptoms -Recurrent, involuntary, distressing memories of the trauma. In children, may appear in play. -Recurrent distressing dreams. -Dissociative reactions (e.g., flashbacks). -Intense psychological distress or physiological reactions to trauma cues. 2. Negative Mood -Persistent inability to experience positive emotions (e.g., happiness, satisfaction, love). 3. Dissociative Symptoms -Altered sense of reality (e.g., time slowing, being in a daze). -Inability to remember important aspects of the trauma (not due to head injury or substances). 4. Avoidance Symptoms -Avoidance of distressing memories, thoughts, or feelings related to the trauma. -Avoidance of reminders (people, places, conversations, activities). 5. Arousal Symptoms -Sleep disturbance. -Irritable behavior and angry outbursts. -Hypervigilance. -Problems with concentration. -Exaggerated startle response. DURATION OF SYMPTOMS IS 3 DAYS TO 1 MONTH AFTER TRAUMA Tell me about the structural dissociation model Defense System: When a child is abused, their defense system will naturally work to shield them from harm, BUT... Attachment System: ...their attachment system will still want to be loved and cared for by the parent. This creates an internal tug-of-war where different motivational systems are working against each other simultaneously. This can cause a patient's conflicting parts to separate. That can lead to a split in their sense of self and a dysregulated nervous system. Define dissociation feelings of detachment from one's own body Define derealization feelings that one's surroundings are not reality Time line with adjustment disorder development of emotional or behavioral symptoms within 3 months of the onset of a new stressor lasts no longer than 6 months Child has had symptoms for 2 months adjustment disorder is most likely. Symptoms do not meet criteria for other diagnoses. Symptoms of adjustment disorder cause significant impairment in social or occupational functioning but do not persist past 6 months after the initial stressor has resolved. What are specifiers for adjustment disorder -depressed mood -anxiety -mixed anxiety and depressed mood -disturbance of conduct -mixed disturbance of emotions and conduct Treatment for adjustment disorder -Family therapy and/or individual therapy -Parent training -Meds usually aren't indicated as it resolves by 6 months DSM5 adjustment disorder in children and adolescents A. Development of emotional or behavioral symptoms in response to an identifiable stressor(s) occurring within 3 months of the onset of the stressor. These symptoms or behaviors are clinically significant, as evidenced by one or both of the following: -Marked distress that is out of proportion to the severity or intensity of the stressor, taking into account the external context and cultural factors. -Significant impairment in social, academic (occupational), or other important areas of functioning Once the stressor or its consequences have terminated, the symptoms do not persist for more than 6 months. DSM5 pediatric considerations adjustment disorder More likely to show behavioral symptoms (e.g., acting out, defiance, school refusal) than internal emotional distress. May present with: -Irritability or aggression -Social withdrawal -Decline in academic performance -Somatic complaints (e.g., headaches, stomachaches) -Separation anxiety or increased clinginess (in younger children) What commonly causes RAD abandonment, severe neglect, or maltreatment. What are symptoms with RAD? difficulty forming emotional attachments to others, have a decreased ability to experience positive emotions, are unable to seek or accept physical or emotional closeness, and can react violently to attempts to hold or cuddle them. Behavior and moods can be unpredictable, with some children appearing to live in a constant state of fight, flight, or freeze mode. Children with RAD are often difficult to discipline or console DSM5 Reactive attachment disorder in children and adolescents A. Consistent pattern of inhibited, emotionally withdrawn behavior toward adult caregivers, manifested by both: -The child rarely or minimally seeks comfort when distressed. -The child rarely or minimally responds to comfort when distressed. B. A persistent social and emotional disturbance characterized by at least two of the following: -Minimal social and emotional responsiveness to others. -Limited positive affect. -Episodes of unexplained irritability, sadness, or fearfulness, even during nonthreatening interactions with caregivers. C. The child has experienced a pattern of extremes of insufficient care, as evidenced by at least one of the following: -Social neglect or deprivation (lack of having basic emotional needs met by caregiving adults). -Repeated changes of primary caregivers (e.g., frequent foster placements). -Rearing in unusual settings that severely limit the opportunity to form selective attachments (e.g., institutions with high child-to-caregiver ratios). Dx between 9 months and 5 years Timeline with prolonged grief disorder persist for at least one year following the death of a loved one in adults and 6 months in children and adolescents Symptoms of prolonged grief disorder disbelief surrounding the death, avoidance of reminders that their loved one is dead, intense emotional pain or numbness, difficulty engaging with friends or interests, loneliness, or a sense of meaninglessness. Children specific symptoms in prolonged grief disorder may express their distress through play, behavior changes, regression, and separation anxiety. Children may also express excessive worry about their health and ask questions about death. They may feel different f