NU606/ NU 606 Exam 2 (2026/ 2027 Updated) Advanced Pathophysiology Guide |Q&A| Grade A| 100% Correct (Accurate Solutions)- Regis

NU606/ NU 606 Exam 2 (2026/ 2027 Updated) Advanced Pathophysiology Guide |Q&A| Grade A| 100% Correct (Accurate Solutions)- Regis Q. Stimulant Medications: Methylphenidate ANSWER -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 Q. Stimulant Medications: Dexmethylphenidate (Focalin) ANSWER -Available in IR and ER -More potent than Ritalin -High risk of adverse effects Q. Stimulant Medications: Amphetamine (Adzenys) ANSWER -available in orally disintegrating ER formula for children who cannot swallow pills -Avoid prescribing when an MAOI has been used within 14 days Q. Stimulant Medications: Dextroamphetamine (Adderall) ANSWER -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 Q. Stimulant Medications: Lisdexamfetamine (Vyvanse) ANSWER -Biologically inactive until metabolized by the body (Prodrug) -Less abuse & diversion potential than other stimulants -Higher-cost medication Q. Non-stimulant medication: Atomoxetine (Strattera) ANSWER -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 Q. Non-stimulant medication: Clonidine ANSWER -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 Q. Non-stimulant medication: guanfacine ANSWER -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 Q. Non-stimulant medication: Bupropion (Wellbutrin) ANSWER -Norepinephrine Dopamine Reuptake Inhibitor -off-label use for ADHD in adults -appropriate for clients with concurrent depression or tobacco abuse Q. Attention-deficit/hyperactivity disorder (ADHD) ANSWER -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 Q. Without early identification and proper treatment, ADHD can cause disruptions in: ANSWER academic performance family stress difficulties in social relationships accidental injuries Q. ADHD is associated with: ANSWER increased rates of depression & SUD Q. Symptoms of ADHD ANSWER -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 Q. When is ADHD most often diagnosed ANSWER -preschool and elementary school • inattentive features become more prominent Q. ADHD Lifespan Considerations: Symptoms Change with Age ANSWER -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 Q. -Adolescents & Adults with ADHD ANSWER • may struggle with executive function, attention, working memory • problems with day-to-day functioning, performance at work, relationships Q. ADHD is a deficiency of neurotransmitters, mainly _________ & _________ ANSWER dopamine and norepinephrine Q. ADHD diagnostic criteria ANSWER -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 Q. 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? ANSWER 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. Q. 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? ANSWER 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 psychotherapy should be provided first. Aniyah is a 7-year-old who presents to the emergency department with complaints of abdominal pain. Her mother endorses a reduced appetite over the past three days, and she has not had a bowel movement in five days. Aniyah has no past medical history. She lives with her mother and older brother; her parents are separated, and her father moved out two months ago. Aniyah is in second grade; her developmental progress is age-appropriate. The medical team completed an assessment including an abdominal x-ray, which shows multiple rectangular radiopaque foreign bodies in the large intestine. After the x-ray was completed, Aniyah admitted to eating pencil erasers daily for the past two months. Which of the following is the most appropriate ICD-10-CM for Aniyah? F98.3 F50.8 F50.9 F32.9 F98.3 Rationale: Aniyah meets the diagnostic criteria for pica: persistent eating of nonfood substances for at least a month, inappropriate to developmental level, and not a part of a culturally supported practice. The ICD-10-CM code for pica in children is F98.3 and for adults is F50.8. Nichole is a 17-year-old who is 29 weeks pregnant with her first child. She has no past medical or psychiatric history. She was referred to the PMHNP (Psychiatric Mental Health Nurse Practitioner) by her obstetrician (OB) after she admitted to cravings for and consumption of paper on a regular basis. Nichole's OB ordered a complete blood count (CBC), comprehensive metabolic profile (CMP), and glucose tolerance test, all of which were normal. Nichole complains of mild heartburn and occasional constipation which she has been treating with over-the-counter antacids and laxatives. Nichole endorses eating about 3-4 sheets of copy paper each day, typically during her restroom breaks at school. She has been doing so for the past 8-10 weeks. She has not discussed this behavior with anyone other than her OB; she states that she finds the behavior "a bit weird and embarrassing." She states that other than eating paper, s no Rationale: Although Nichole believes her behavior is "weird and embarrassing," she does not meet the diagnostic criteria for pica. Although she has been consuming nonfood substances for over a month, her behavior is occurring in the context of her pregnancy and the ingestion of paper does not pose potential medical risks. Avoidant/restrictive food intake disorder (ARFID) -added to the DSM-5 in 2013 -reduced intake of food volume or variety due to: • fear of aversive consequences of eating • lack of interest in food or eating • sensory sensitivity to food -thought to be as prevalent as anorexia nervosa & bulimia nervosa -associated with nutritional, medical, and/or psychosocial impairment -Children with ARFID typically eat only a few preferred food items • do not meet nutritional needs • habitual food avoidance which affects their weight & nutritional health • mealtime often disruptive behaviors, spitting food out, batting it away, holding food in the mouth, refusing to swallow it, escapist actions increased risk for ARFID -Children with mental health conditions including: • anxiety disorders • OCD • autism spectrum disorder • ADHD • intellectual disabilities -presence of a maternal eating disorder -Hx of: • GERD • vomiting • other medical problems Avoidant/restrictive food intake disorder (ARFID) DSM-5-TR dx requires each of the following: -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. Lillian is a 9-year-old who presents with her mother after a referral from the pediatrician. Lillian is 54 inches tall and currently weighs 55 pounds (lbs). As a toddler, Lillian ate most of the foods offered to her. When she was 6, she witnessed her grandmother choke on a piece of meat and receive the Heimlich maneuver; her grandmother survived, but since then, Lillian refused to eat meat. Over the past three years, her eating has become more restricted; she will no longer eat anything that requires chewing. Her mother has been offering soups, purees, and nutritional supplements, but Lillian has failed to gain weight as she grows taller. Lillian endorses that she is frequently bullied at school for her refusal to eat at lunch and during classroom parties. Does Lillian meet the diagnostic criteria for ARFID? yes no unable to determine Yes Rationale: Lillian meets the diagnostic criteria for ARFID. She presents with avoidance of eating food based on the sensory characteristics of the food and failure to meet expected weight gain appropriate for age and height. The behavior interferes with her psychosocial functioning and is not better explained by cultural practice, lack of available food, or anorexia nervosa. David is a 14-year-old who presents with his mother who voices concerns about his behavior. David is 65 inches tall and weighs 102 lbs. David has been active in competitive wrestling since age 9 and dreams of joining the U.S. Olympic team. Since starting high school, David has become preoccupied with his body shape and body fat percentage. He constantly worries about "making weight" for wrestling meets. Rather than eating lunch at school, he goes to the weight room to exercise. David's mom endorses that when he gets home from wrestling practice, he eats "huge amounts" of food. Typically, David will eat an entire frozen pizza before dinner and then have second helpings during the family meal. He eats dessert and then "disappears" into the bathroom immediately following dinner. David's parents became concerned after hearing retching sounds in the bathroom. Upon interview, David admits that when he start bulimia nervosa Rationale: David meets the diagnostic criteria for bulimia nervosa. He eats excessive amounts of food in a discrete period and has a loss of sense of control over his eating. After bingeing, he purges and uses laxatives to prevent weight gain. His self-image is influenced by body shape and weight. Angela is a 15-year-old who presents for an evaluation due to recent weight loss. She is 63 inches tall and has lost 12 lbs. in the past 3 months. Her current weight is 89 lbs. Angela was active in several extracurricular activities, including soccer, choir, and cheerleading, until three months ago. She has become more withdrawn from social interactions with friends and, according to her parents, spends most of her time in her room sleeping. She refuses to join the family for dinner and instead takes a plate to her bedroom; her mother endorses that most of the food returns to the kitchen uneaten. Angela states that she skips breakfast and does not eat in the lunchroom at school, but she will take a sandwich into the girls' locker room and eat it in a stall during her lunch period. Angela states that she believes she is unattractive and admits she is probably too thin, but she does not care because she is too tired major depressive disorder Rationale: Angela meets the diagnostic criteria for major depressive disorder. She has withdrawn from extracurricular and social activities, lost a significant amount of weight, and displays hypersomnia. She has feelings of worthlessness and fatigue. Although Angela's BMI is in the 2nd percentile, she is aware that she is too thin and does not fear gaining weight; therefore, she does not meet the diagnostic criteria for an eating disorder. Ronnita is a 17-year-old who presents with her mother who voices concerns about her recent weight loss. Ronnita began the school year at 64 inches tall weighing 106 lbs. She joined the cross country team; initially, she practiced with the team and came home immediately after. Now, she runs an additional 6-10 miles per day after team practice and has lost 14 lbs. in 5 months. Her mother endorses that Ronnita makes daily comments about how fat she still is and how much more weight she needs to lose to get to her ideal body size. Although Ronnita is otherwise physically healthy, her pediatrician recommended a consultation with a mental health provider to assess for a possible eating disorder. Rather than eating at school, Ronnita tutors her peers in the student learning center during her lunch period. Ronnita's parents require her to sit at the table for dinner, but her mother endorses that she cuts her food into tiny anorexia nervosa, binge-eating/purging type Rationale: Ronnita meets the diagnostic criteria for anorexia nervosa, binge eating/purging type. She has a restricted food intake leading to significantly low body weight and fear of becoming fat. Her exercise regimen and eating behaviors interfere with weight gain even though she is already at a significantly low weight with a BMI of less than the 1st percentile for age. She has a disturbance in her evaluation of her body weight and shape, and she has engaged in recurrent episodes of purging behaviors as well. Preston is a 19-year-old college sophomore who presents with complaints of low mood and fatigue. Preston endorses having difficulty building a new social network since starting college; he lives on campus but spends most of his time outside of class alone in his single dorm room. He has an unlimited meal plan, and he buys food in the cafeteria and the campus convenience store to take back and eat in his room. When asked why he does not eat in the cafeteria, Preston states that he does not like others to watch him eat because he eats "too fast and too much." He notes that he usually eats until he feels overly full and then has no energy to do anything but lay down and play on his phone or sleep. He feels disgusted with himself on a regular basis because of this behavior but notes that he cannot seem to control his eating once he starts. Preston states that he has been overweight since he was a child; he endorses g major depressive disorder BED Rationale: Preston meets the criteria for BED, including consuming a large amount of food in a discrete period with a lack of control over his behavior. He eats more rapidly than normal and eats until he is uncomfortable. He feels disgusted with himself after overeating. He does not use inappropriate compensatory behaviors that would indicate bulimia nervosa. Preston also meets the diagnostic criteria for major depressive disorder: he has low mood, diminished pleasure in activities, fatigue, weight gain, and hypersomnia. Screening for Eating Disorders: SCOFF tool -five-item measure • 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? Screening for Eating Disorders: PARDI The Pica, ARFID, and Rumination Disorder Interview (PARDI) -clinical assessment tool -designed to assess & diagnose pica & ARFID -PARDI Parent/Carer 2-3 and Parent/Carer 4+ • modified for use with children and their caregivers -PARDI Self 8-13 and Self 14+ • used with adolescents -preliminary support for validity and reliability Anorexia Nervosa Tx -multidisciplinary • psychotherapy & pharmacological interventions -Tx goals • restoration of sufficient nutrition • return to a healthy weight • reduction of excessive exercise • elimination of binge-purge & binge-eating behaviors • primary goal in medically stable AN pt is weight gain -Psychotherapy is essential -family therapy & CBT are effective modalities, can be implemented with tx manuals specific to anorexia nervosa -Medications can help address comorbid psychopathologies: • depressive disorders, anxiety disorders, OCDs -Psychotherapy • outpatient setting, through partial hospitalization programs (day-treatment), or in residential tx settings -majority managed with outpatient therapy Anorexia: What Therapists and Parents Need to Know -Family Based Treatment (FBT) • Most successful therapy is based on parents helping their child • Twice as effective for recovery than ind. therapy • a quarter of the incidence of relapse *If you have an adolescent with anorexia nervosa who is medically stable, Family Based Treatment should be the first line tx Family-Based Treatment for Eating Disorders -one of the most successful treatments for eating disorders in children and teens with anorexia nervosa, bulimia nervosa, and other specified feeding or eating disorder (OSFED) -sometimes called "Maudsley Family Therapy," (development at Maudsley Hospital in London) -involves the whole family in solving their child's eating disorder -does not blame the family -prescribes family sessions with a therapist at first once a week, decreasing over the course of tx • typically at least one family meal at beginning of tx in therapist's office Bulimia Nervosa and BED Tx -combining antidepressant meds with psychotherapy • AVOID BUPROPION risk of seizures with active symptoms of bulimia nervosa -Lisdexamfetamine approved for moderate to severe BED in adults -no med FDA approved for children/adolescents with BED -CBT for bulimia nervosa and BED -Brief strategic therapy pharmacological tx for bulimia nervosa