PCPs need teachers to complete the NICHQ Vanderbilt Assessment
Scale!
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PCPs are commonly using many other mental health screening
tools NICHQ Parent- & Teacher- report Vanderbilt Assessment
Scales: screens for ADHD, ODD, conduct disorder, depression/anxiety
NICHQ Parent- & Teacher- report Vanderbilt Assessment Scales:
screens for ADHD, ODD, conduct disorder, depression/anxiety Screen
for Child Anxiety Related Disorders (SCARED): screens for anxiety
disorders Screen for Child Anxiety Related Disorders (SCARED):
screens for anxiety disorders Patient Health Questionnaire for
Adolescents (PHQ-A): screens for depression & suicidality
Patient Health Questionnaire for Adolescents (PHQ-A): screens for
depression & suicidality CRAFFT: screens for substance abuse
CRAFFT: screens for substance abuse
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Condition #2 (the Hulk): ADHD with co-occuring Oppositonal
Defiant Disorder +/- Conduct Disorder.
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ADHD & Co-occurring Disorders Pediatricians can diagnose
& treat children with ADHD & co-occurring behavioral
disorders from preschool age through adolescence. Both medications
(stimulants, selective norepinephrine reuptake inhibitors &
alpha adreneric agents) & behavioral therapy with a trained
mental health provider are effective & safe treatments for
ADHD. Effective treatments require appropriate titration &
ongoing monitoring to remain maximally effective.
Know When & How To Effective Collaborate with PCPs &
Directly Refer Children to a Mental Health Provider Yes,
cognitive-behavioral therapy (CBT) and a SSRI medication often
improves anxiety & depression symptoms in children &
adolescents. Yes, cognitive-behavioral therapy (CBT) and a SSRI
medication often improves anxiety & depression symptoms in
children & adolescents. However, a proper mental health
evaluation with a qualified professional is the best next step.
However, a proper mental health evaluation with a qualified
professional is the best next step. Remember, the DSM-V is 947
pages long! Remember, the DSM-V is 947 pages long!
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DSM-V Disorders Depressive Disorders : Disruptive Mood
Dysregulation Disorder Disruptive Mood Dysregulation Disorder Major
Depressive Disorder (Single vs. Recurrent episode) Major Depressive
Disorder (Single vs. Recurrent episode) Persistent Depressive
Disorder (Dysthymia) Persistent Depressive Disorder (Dysthymia)
Premenstrual Dysphoric Disorder Premenstrual Dysphoric Disorder
Substance/Medication-Induced Depressive Disorder
Substance/Medication-Induced Depressive Disorder Depressive
Disorder Due to Another Medical Condition Depressive Disorder Due
to Another Medical Condition Other Specified Depressive Disorder
Other Specified Depressive Disorder Unspecified Depressive Disorder
Unspecified Depressive Disorder Bipolar and Related Disorders
Bipolar I Disorder Bipolar I Disorder Bipolar II Disorder Bipolar
II Disorder Cyclothymic Disorder Cyclothymic Disorder Bipolar
Disorder and Related Disorder Due to Another Medical Condition
Bipolar Disorder and Related Disorder Due to Another Medical
Condition Other Specified Bipolar and Related Disorder Other
Specified Bipolar and Related Disorder Unspecified Bipolar and
Related Disorder Unspecified Bipolar and Related Disorder
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DSM-V Disorders Anxiety Disorders: Separation Anxiety Disorders
Separation Anxiety Disorders Selective Mutism Selective Mutism
Specific Phobia Specific Phobia Social Anxiety Disorder (Social
Phobia) Social Anxiety Disorder (Social Phobia) Panic Disorder
Panic Disorder Agoraphobia Agoraphobia Generalized Anxiety Disorder
Generalized Anxiety Disorder Substance/Medication-Induced Anxiety
Disorder Substance/Medication-Induced Anxiety Disorder Anxiety
Disorder Due to Another Medical Condition Anxiety Disorder Due to
Another Medical Condition Other Specified Anxiety Disorder Other
Specified Anxiety Disorder Unspecified Anxiety Disorder Unspecified
Anxiety Disorder Obsessive-Compulsive Related Disorders Trauma- and
Stressor-Related Disorders Dissociative Disorders Somatic Symptom
and Related Disorders Feeding and Eating Disorders Elimination
Disorders Sleep-Wake Disorders, etc.
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Condition #5: Elimination Disorders like Chronic Constipation
with Encopresis
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Constipation in Children 4-18 Years Two of the following
present for at least two months: 1.Two or fewer defecations per
week 2.At least one episode of fecal incontinence per week
3.History of retentive posturing or excessive volitional stool
retention 4.History of painful or hard bowel movements 5.Presence
of a large fecal mass in the rectum 6.History of large-diameter
stools that may obstruct the toilet
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Constipation (over 95% is Functional or not Organic) Classic
History Usually begins or worsens soon after the child starts
school. Usually begins or worsens soon after the child starts
school. Child has painful bowel movements Child has painful bowel
movements When urge to have a bowel movement happens, the child
consciously withholds stool by contracting their external anal
sphincter and gluteal muscles When urge to have a bowel movement
happens, the child consciously withholds stool by contracting their
external anal sphincter and gluteal muscles The child might rise on
their toes, rock back & forth, stiffens their buttocks &
legs, assume unusual postures, & will often hide in a corner
The child might rise on their toes, rock back & forth, stiffens
their buttocks & legs, assume unusual postures, & will
often hide in a corner Eventually, the rectum habituates to the
stimulus of the enlarging fecal mass, the urge to defecate
subsides, and the retentive behavior becomes almost second nature
or subconscious Eventually, the rectum habituates to the stimulus
of the enlarging fecal mass, the urge to defecate subsides, and the
retentive behavior becomes almost second nature or subconscious Can
eventually develop soiling in underwear (encopresis) Can eventually
develop soiling in underwear (encopresis)
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Constipation Treatment: Education Family friendly explanation
of constipation Family friendly explanation of constipation
Reassure parents that this is not a willful or defiant behavior
Reassure parents that this is not a willful or defiant behavior
Maintain consistent, positive, supportive attitude for the child
Maintain consistent, positive, supportive attitude for the child
Avoid punishing the child & establish a reward system! Avoid
punishing the child & establish a reward system! Ensure
adequate dietary fiber intake & use fiber supplement Ensure
adequate dietary fiber intake & use fiber supplement Goal = BM
2x daily for 10-15 min after breakfast & dinner Goal = BM 2x
daily for 10-15 min after breakfast & dinner Take advantage of
the gastrocolic reflex Take advantage of the gastrocolic reflex Sit
up straight with thighs parallel to ground Sit up straight with
thighs parallel to ground Valsalva maneuver to increase abdominal
pressure Valsalva maneuver to increase abdominal pressure No
distractions while the child is pooping! No distractions while the
child is pooping!
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Constipation/Encopresis Treatment: Meds 1. Clean out phase or
disimpaction with oral Miralax 1-2 y: 2 tsps with 4 oz of Gatorade,
repeat every hour until stools are clear. 1-2 y: 2 tsps with 4 oz
of Gatorade, repeat every hour until stools are clear. 3-5 y: 4
capfuls in 24 oz of Gatorade, given 4 oz every 30 60 min. 3-5 y: 4
capfuls in 24 oz of Gatorade, given 4 oz every 30 60 min. 6-11 y: 6
capfuls in 32 oz of Gatorade, given 4 oz every 30-60 min. 6-11 y: 6
capfuls in 32 oz of Gatorade, given 4 oz every 30-60 min. >12 y:
8 capfuls in 32 oz of Gatorade, given 4 oz every 30-60 min. >12
y: 8 capfuls in 32 oz of Gatorade, given 4 oz every 30-60 min.
Clean out phase or disimpaction with oral stimulant laxative Clean
out phase or disimpaction with oral stimulant laxative Age 3-11 y:
Bisacodyl 5 mg PO at beginning and end of cleanout Age 3-11 y:
Bisacodyl 5 mg PO at beginning and end of cleanout Age 12 and up:
Bisacodyl 10 mg PO at beginning & end of cleanout Age 12 and
up: Bisacodyl 10 mg PO at beginning & end of cleanout 2.
Maintenance phase with oral Miralax: 0.4 to 0.8 grams/kg per day in
2 to 8 oz of a Gatorade (max of 17 g daily is a good starting dose
) 0.4 to 0.8 grams/kg per day in 2 to 8 oz of a Gatorade (max of 17
g daily is a good starting dose ) Taper or titrate dose of Miralax
as needed to get runny oatmeal stools Taper or titrate dose of
Miralax as needed to get runny oatmeal stools
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Constipation: Treatment Goals 1 to 2 soft (mashed potato, runny
oatmeal or soft ice cream) stools per day 1 to 2 soft (mashed
potato, runny oatmeal or soft ice cream) stools per day Resolution
of soiling in underwear Resolution of soiling in underwear Return
of rectal sensation Return of rectal sensation Empowerment of child
Empowerment of child Make defecation a positive experience Make
defecation a positive experience
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Please help swiftly identify & address DB problems in
children & their families by collaborating closely with
PCPs.
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EARLY INTERVENTIONERS ASSEMBLE! The theme is team!
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This book provides systematic, big-picture guidance and
specific information about how to develop or strengthen your own
communitys early detection/Child Find system.