Pearls for PrActioners




Chapter 16


Somatic Symptom and Related Disorders





  • Involve physical symptoms (pain, fatigue, or loss of function) that may be medically unexplained or that may accompany diagnosed medical disorders.



  • Elevated rates of medical utilization are common (patients repeatedly seek reassurance from family, friends, and medical staff regarding their health).



  • In early childhood, symptoms often include recurrent abdominal pain (RAP). Later headaches, neurological symptoms, insomnia, and fatigue are common.



  • Screening tools for somatic symptom and related disorders (SSRDs) include the Children’s Somatization Inventory, Illness Attitude Scales, Soma Assessment Interview, and the Functional Disability Inventory.



  • Selective serotonin reuptake inhibitors (SSRIs) benefit SSRDs involving unexplained headaches, fibromyalgia, body dysmorphic disorder, pain disorder, irritable bowel syndrome, and functional gastrointestinal disorders.



  • Tricyclic antidepressants should be avoided in youth with functional abdominal pain (FAP), because they have little proven efficacy and are very dangerous in overdose.



  • Stimulants may also be helpful in chronic fatigue syndrome (CFS).



  • Therapy, such as cognitive-behavioral therapy (CBT), has demonstrated efficacy in treating recurrent pain, CFS, fibromyalgia, and FAP. Self-management strategies (self-monitoring, relaxation, hypnosis, and biofeedback) have also demonstrated efficacy.



  • Home schooling should be avoided; school attendance and performance should be emphasized; parents should limit attention/reinforcement for pain behavior; and normal routines/appropriate schedules (e.g., going to school) should be emphasized.





Chapter 17


Anxiety Disorders





  • Characterized by uneasiness, excessive rumination, and apprehension about the future.



  • Tend to be chronic, recurring, and vary in intensity over time.



  • Medical conditions (e.g., hyperthyroidism, medication side effects, substance abuse, or other medical conditions) should be ruled out.



  • First-line treatment for mild to moderate anxiety includes evidence-based psychotherapies and psychoeducation. CBT (e.g., systematic desensitization, exposure techniques, operant conditioning, modeling, and cognitive restructuring) can be beneficial in anxiety disorders.



  • SSRIs are the medication of choice. The FDA approved SSRIs for children are fluoxetine, sertraline, and fluvoxamine. They can initially exacerbate anxiety or even panic symptoms. Tricyclic antidepressants have also shown efficacy.



  • Benzodiazepines (e.g., clonazepam) include a risk of causing disinhibition in children.



  • Alpha-2a-agonists (guanfacine and clonidine) may be useful with autonomic symptoms.



  • Anticonvulsant agents (e.g., gabapentin) are used when other agents are ineffective.



  • β-Blockers help with performance anxiety.





Chapter 18


Depressive Disorders and Bipolar Disorders


Depressive Disorders




  • Depressive disorders involve the presence of sad/irritable mood along with physical and cognitive impacts on the child’s daily functioning.



  • In children, depressed mood often presents as irritability and/or restlessness. Furthermore, many children/adolescents complain of pervasive boredom in major depressive disorder (MDD).



  • Many depressive disorders demonstrate genetic predispositions. Anxiety disorders, substance disorders, and conduct/disruptive disorders frequently present as co-morbid with MDD.



  • Screening tools such as Kovacs Children’s Depression Inventory (CDI) may be helpful.



  • SSRIs are first-line pharmacological treatments. Fluoxetine is the only FDA approved medication for treatment of youth. “Off label” medications such as citalopram, escitalopram, paroxetine, and venlafaxine also have positive clinical trial results.



  • An antidepressant should be given an adequate trial (6 weeks at therapeutic doses) before switching or discontinuing unless there are serious side effects. For a first episode of depression, treatment for 6-9 months after remission of symptoms is recommended.



  • Psychotherapy appears to have good efficacy in mild to moderate depression. In moderate to severe depression, combined treatment with psychotherapy and medication has the greatest rate of response, and CBT and interpersonal therapies have received the most empirical support.



  • Suicidal ideation and attempts at suicide are high in depressive disorders. Regular assessment of suicidal ideation should occur.

Bipolar Disorders (BD)


  • Consist of distinct periods of mania (elevated, expansive, or irritable mood) and persistent goal-directed activity or energy that may alternate with periods of severe depression.



  • Often present with rapid shifts in mood or lability over brief time frames (e.g., shifting between euphoria and dysphoria or irritability). A decreased need for sleep is also common.



  • FDA-approved medications in adults (used “off label” in children) include the following: lithium, divalproex sodium, carbamazepine, olanzapine, risperidone, quetiapine, ziprasidone, and aripiprazole. Lithium is often used in acute episodes and as a maintenance treatment in children and adolescents, but this requires periodic monitoring of blood levels.



  • Anticonvulsants are used for mixed or rapid cycling cases in adults. They have also been used effectively in youth, but they are not FDA-approved in children for BD.



  • Neuroleptics have had positive results in youth with BD; however, the increased risk of tardive dyskinesia should be considered in using such agents.


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Jun 24, 2019 | Posted by in PEDIATRICS | Comments Off on Pearls for PrActioners
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