Pediatrics_Nelson

Pediatrics_Nelson. Most children who have temper tantrums have no underlyingmedical problem. Hearing loss and language delay may be associated with temper tantrums. Children with brain injury andother brain disorders are at increased risk for prolonged temper


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Pediatrics_Nelson. Attention deficit/hyperactivity disorder (ADHD) is a neurobehavioral disorder defined by symptoms of inattention, hyperactivity, and impulsivity. Clinical guidelines emphasize the use ofthe Diagnostic and Statistical Manual of Mental Health Disorders,Fifth Edition, criteria (available at http://www.cdc.gov/ncbddd/adhd/diagnosis.html) to diagnose ADHD. Diagnosis of childrenup to the age of 16 years requires the presence of at least 6 symptoms of inattention or 6 symptoms of hyperactivity-impulsivityfor at least 6 months in two or more environments. Children 17 years of age and older must exhibit at least 5 symptoms ofinattention or at least 5 symptoms of hyperactivity-impulsivity.Symptoms of inattention include: failing to pay close attentionto details, appearing to not listen when spoken to directly, failing to follow through on instructions or finish assigned work,having difficulty sustaining attention during tasks or play, having difficulty organizing tasks or activities, avoiding


Pediatrics_Nelson

Pediatrics_Nelson. to directly, failing to follow through on instructions or finish assigned work,having difficulty sustaining attention during tasks or play, having difficulty organizing tasks or activities, avoiding or dislikingactivities that require sustained mental effort (e.g., schoolwork),frequently losing things required for tasks and activities, becoming easily distracted, and experiencing frequent forgetfulness indaily activities. Symptoms of hyperactivity include: being fidgetyor restless, leaving a seat when expected to remain seated, running or climbing excessively in inappropriate situations, havingdifficulty in playing quietly, acting as if “driven by a motor,” andtalking excessively. Symptoms of impulsivity include: blurting out answers before a question has been completed, having difficulty awaiting his or her turn, and causing frequent interruptions or intrusions. In addition, several symptoms must havebeen present prior to 12 years of age; evidence of significantimpairment in social,


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Pediatrics_Nelson. awaiting his or her turn, and causing frequent interruptions or intrusions. In addition, several symptoms must havebeen present prior to 12 years of age; evidence of significantimpairment in social, academic, or work settings must occur;and other mental disorders must be excluded.


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Pediatrics_Nelson. ADHD is multifactorial in origin, with genetic, neural, and environmental contributions. Twin studies and family studies demonstrate high heritability (0.8) and greater risk of developing ADHD in first-degree relatives. Candidate genes include those involving the dopaminergic and noradrenergic neurotransmitter systems. Neuroimaging studies (functional magnetic resonance imaging and positron emission tomography, commonly recognized as fMRI and PET, respectively) have shown structural and functional differences, particularly of the frontal lobes, inferior parietal cortex, basal ganglia, corpus callus, and cerebellar vermis. Prenatal exposure to substances (e.g., nicotine, alcohol) and damage to the central nervous system from trauma or infection increase the risk of ADHD.


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Pediatrics_Nelson. U.S. prevalence rates for ADHD vary, depending on criteria used and population studied, with rates typically in the 5% to 10% range. The male to female ratio is 2 to 6:1, with greater male predominance for the hyperactive/impulsive and combined types. Girls often present with inattentive symptoms and are more likely to be underdiagnosed or to receive later diagnoses. Symptoms of ADHD, particularly impulsivity and inattention, persist into adolescence and adulthood in 60% to 80% of patients. ADHD is diagnosed clinically by history. Open-ended questions should focus on specific behaviors and their impact on academic performance, family and peer relationships, safety, self-esteem, and daily activities. Information should be gathered from the family and the school via ADHD-specific rating scales such as the Conners’ Rating Scales or the Vanderbilt Rating Scales.


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Pediatrics_Nelson. A physical examination is essential to identify medical(e.g., neurologic, genetic) or developmental problems (e.g.,cognitive impairment, language disorder, learning disability, autism spectrum disorder) that may underlie, coexist,or provide an alternative explanation for the child’s behaviors. Observation of the child, the parents, and their interactions is part of the evaluation. Keep in mind that childrenwith ADHD can typically focus without hyperactivity in environments with low stimulation and little distraction (e.g., clinician’s office). Laboratory and imaging studies are not routinely recommended but may help exclude other conditions. Consider thyroid function studies, blood lead levels, genetic studies, and brain imaging studies if indicated by medical history, environmental history, or physical examination.


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Pediatrics_Nelson. The clinician should first consider the child’s developmental level to determine whether the behaviors are within the range of normal. Medical conditions, such as sleep disordered breathing, seizure disorders, substance use, hyperthyroidism, lead intoxication, and sensory deficits, should beconsidered as possible causes for a child’s hyperactivity anddistractibility. Inattention and hyperactivity may be presentas features of genetic disorders such as fragile X, 22q11.2deletion syndrome, and neurofibromatosis 1. Chaotic living situations or psychological stress (e.g., bullying, abuse)can also lead to symptoms of hyperactivity, impulsivity, andinattention. Children who have symptoms of ADHD in onlyone setting may be having problems due to cognitive level,level of emotional maturity, or feelings of well-being in thatsetting.


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Pediatrics_Nelson. More important, coexisting conditions are present in up to 60% of children with ADHD. These include psychiatric conditions, particularly oppositional defiant disorder, conduct disorder, anxiety disorder, and depression; learning disabilities; language disorders; and tic disorders. These conditions are also part of the differential diagnosis of ADHD. Management begins with recognizing ADHD as a chronic condition and educating affected children and their parents about the diagnosis, treatment options, and prognosis. Table 13-1 FDA-Approved Medications for Attention-Deficit/Hyperactivity Disorder GENERIC MEDICATION BRAND NAME INITIAL-MAXIMUM DOSE DURATION (h) STIMULANTS Mixed amphetamine salts Adderall* Adderall XR* 2.5 mg–40 mg 5 mg–40 mg 6 10 Dexmethylphenidate Focalin* 2.5 mg–20 mg 3–5 Focalin XR 5 mg–30 mg 8–12 Atomoxetine Strattera 0.5 mg/kg/d then increase to 1.2 mg/kg with max 1.4 mg/kg At least 10–12 40 mg/d for adults and children weighing >154 lb titrate up to 100 mg/d


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Pediatrics_Nelson. Atomoxetine Strattera 0.5 mg/kg/d then increase to 1.2 mg/kg with max 1.4 mg/kg At least 10–12 40 mg/d for adults and children weighing >154 lb titrate up to 100 mg/d Clonidine Kapvay 0.1 mg/d–0.4 mg/d At least 10–12 Adapted from AAP: Implementing the key action statements: an algorithm and explanation for process of care for the evaluation, diagnosis, treatment, and monitoring of ADHD in children and adolescents. Pediatrics SI1–SI21, 2011. *Available in generic form. †Dosages for the dermal patch are not equivalent to those of the oral preparations.


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Pediatrics_Nelson. *Available in generic form. †Dosages for the dermal patch are not equivalent to those of the oral preparations. Anticipatory guidance includes providing proactive strategies to mediate adverse effects on learning, school functioning, social relationships, family life, and self-esteem. Children with ADHD respond to behavioral management, including structure, routine, consistency in adult responses to their behaviors, and appropriate behavioral goals. Children also benefit when parents and clinicians work with teachers to address the child’s needs. Daily behavior report cards and accommodations may be helpful. Social skills training or additional mental health treatments may assist some children with behavior change or preservation of self-esteem, particularly when they have coexisting developmental or mental health conditions also requiring treatment.


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Pediatrics_Nelson. Stimulant medications (methylphenidate or amphetamine compounds) are the first-line agents for treatment of ADHD due to extensive evidence of effectiveness and safety. Stimulant medications are available in short-acting, intermediate-acting, and long-acting forms. Preparations include liquid, tablets, capsules, and a transdermal patch. These options allow the clinician to tailor the choice of medication to the child’s needs. Nonstimulant medications, including atomoxetine (norepinephrine-reuptake inhibitor), guanfacine, or clonidine (alpha agonists), may be helpful in situations such as nonresponse to stimulant medication, family preference, concerns about medication abuse or diversion, and coexisting tic or sleep problems. ADHD medication options are listed in Table 13-1. Common side effects include appetite suppression and sleep disturbance with stimulant medications, gastrointestinal tract symptoms with atomoxetine, and sedation with alpha agonists. These side effects usually can


Pediatrics_Nelson

Pediatrics_Nelson. include appetite suppression and sleep disturbance with stimulant medications, gastrointestinal tract symptoms with atomoxetine, and sedation with alpha agonists. These side effects usually can be managed by careful adjustment of medication dosage and timing. Screening (by history and exam) for cardiac disease and monitoring of cardiac status is prudent given concerns raised by a retrospective study suggesting extremely rare but slightly increased odds of sudden cardiac death in those taking stimulant medication.


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Pediatrics_Nelson. ADHD may be associated with academic underachievement, difficulties in interpersonal relationships, and poor self-esteem. These can have long-reaching effects (e.g., lower levels of educational, employment attainment). Adolescents with ADHD, particularly those who are untreated, are at increased risk for high-risk behaviors such as drug use, early sexual activity, and automobile accidents. Despite parental concerns of illicit drug use and addiction from stimulant medication, there is actually decreased risk of drug abuse in children and adolescents with ADHD who are appropriately medically managed.


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Pediatrics_Nelson. Child-rearing practices including promoting calm environments and opportunities for age-appropriate activities thatrequire increasing levels of focus may be helpful. Limitingtime spent watching television and playing rapid-responsevideo games also may be prudent because these activities reinforce short attention span. Early implementation of behaviormanagement techniques may assist in curtailing problematicbehaviors before they result in significant impairment. Secondary disabilities can be prevented by educating medicalprofessionals and teachers about the signs and symptoms ofADHD and the most appropriate behavioral and pharmaceutical interventions. Collaboration between health care providers, educational professionals, and mental health clinicians will enhance the early identification of and provision ofservices to children at risk for ADHD.


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Pediatrics_Nelson. Development of control of urination and defecation involvesphysical and cognitive maturation and is strongly influenced by cultural norms, socioeconomic status, and practices within the United States and throughout the world. Inthe first half of the twentieth century, toilet mastery by 18months of age was the norm in the United States. Concernabout harsh toilet training and possible later psychologicaldistress led to professional endorsement of later toilet training. In 1962 Brazelton introduced the child-centered approach,which respects the child’s autonomy and pride in mastery.The invention of disposable diapers also facilitated later toilettraining. Social changes, including increased maternal workoutside of the home and group child care, also have influencedthis trend. Some families choose to wait until the child is older because the duration of the training period may be shorter.Toilet training usually begins after the second birthday andis achieved at about 3 years of age in


Pediatrics_Nelson

Pediatrics_Nelson. choose to wait until the child is older because the duration of the training period may be shorter.Toilet training usually begins after the second birthday andis achieved at about 3 years of age in middle-class white U.S.populations. Toilet training between 12 and 18 months of agecontinues to be accepted in lower-income families.


Pediatrics_Nelson

Pediatrics_Nelson. Prerequisites for achieving elimination in the toilet include the child’s ability to recognize the urge for urination and defecation, to get to the toilet, to understand the sequence of tasks required, to avoid oppositional behavior, and to take pride in achievement. The entire process of toilet training can take 6 months and need not be hurried. Successful parent-child interaction around the goal of toilet mastery can set the stage for future active parental teaching and training (e.g., manners, kindness, rules and laws, and limit setting).


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Pediatrics_Nelson. Enuresis is urinary incontinence in a child who is adequately mature to have achieved continence. Enuresis is classified as diurnal (daytime) or nocturnal (nighttime). In the United States, daytime and nighttime dryness are expected by 4 and 6 years of age, respectively. Another useful classification of enuresis is primary (incontinence in a child who has never achieved dryness) and secondary (incontinence in a child who has been dry for at least 6 months).


Pediatrics_Nelson

Pediatrics_Nelson. Enuresis is a symptom with multiple possible etiologic factors, including developmental difference, organic illness, orpsychological distress. Primary enuresis often is associated with a family history of delayed acquisition of bladder control. A genetic etiology has been hypothesized, and familialgroups with autosomal dominant phenotypic patterns fornocturnal enuresis have been identified. Although most children with enuresis do not have a psychiatric disorder, stressfullife events can trigger loss of bladder control. Sleep physiology may play a role in the etiology of nocturnal enuresis, with ahigh arousal threshold commonly noted. In a subgroup ofenuretic children, nocturnal polyuria relates to a lack of anocturnal vasopressin peak. Another possible etiology is malfunction of the detrusor muscle with a tendency for involuntary contractions even when the bladder contains smallamounts of urine. Reduced bladder capacity can be associatedwith enuresis and is commonly seen in children


Pediatrics_Nelson

Pediatrics_Nelson. muscle with a tendency for involuntary contractions even when the bladder contains smallamounts of urine. Reduced bladder capacity can be associatedwith enuresis and is commonly seen in children who havechronic constipation with a large dilated distal colon, whichimpinges on the bladder.


Pediatrics_Nelson

Pediatrics_Nelson. Enuresis is the most common urologic condition in children.Nocturnal enuresis has a reported prevalence of 15% in 5-yearolds, 7% in 8-year-olds, and 1% in 15-year-olds. The spontaneous remission rate is reported to be 15% per year. The oddsratio of nocturnal enuresis in boys compared with girls is 1.4:1.The prevalence of daytime enuresis is lower than nocturnalenuresis but has a female predominance, 1.5:1 at 7 years of age.Of children with enuresis, 22% wet during the day only, 17%wet during the day and at night, and 61% wet at night only. Available @ StudentConsult.com


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Pediatrics_Nelson. The history focuses on elucidating the pattern of voiding: How often does wetting occur? Does it occur during the day, night, or both? Are there any associated conditions with wetting episodes (e.g., bad dreams, consumption of caffeinated beverages, or exhausting days)? Has the child had a period of dryness in the past? Did a stressful event precede the change in wetting pattern? A review of systems should include a developmental history and detailed information about the neurologic, urinary, and gastrointestinal systems (including patterns of defecation). A history of sleep patterns also is important, including snoring, parasomnias, and timing of nighttime urination. A family history often reveals that one or both parents had enuresis as children. Although enuresis is rarely associated with child abuse, physical and sexual abuse history should be included as part of the psychosocial history. Many families have tried numerous interventions before seeking a physician’s help.


Pediatrics_Nelson

Pediatrics_Nelson. with child abuse, physical and sexual abuse history should be included as part of the psychosocial history. Many families have tried numerous interventions before seeking a physician’s help. Identifying these interventions and how they were carried out aids the understanding of the child’s condition and its role within the family.


Pediatrics_Nelson

Pediatrics_Nelson. The physical examination begins with observation of thechild and the parent for clues about child developmental andparent-child interaction patterns. Special attention is paid tothe abdominal, neurologic, and genital examination. A rectalexamination is recommended if the child has constipation.Observation of voiding is recommended if a history of voiding problems, such as hesitancy or dribbling, is elicited. Thelumbosacral spine should be examined for signs of spinaldysraphism or a tethered cord.


Pediatrics_Nelson

Pediatrics_Nelson. For most children with enuresis, the only laboratory test recommended is a clean catch urinalysis to look for chronic urinary tract infection (UTI), renal disease, and diabetes mellitus. Further testing, such as a urine culture, is based on the urinalysis. Children with complicated enuresis, including children with previous or current UTI, severe voiding dysfunction, or a neurologic finding, are evaluated with a renal sonogram and a voiding cystourethrogram. If vesicoureteral reflux, hydronephrosis, or posterior urethral valves are found, the child is referred to a urologist for further evaluation and treatment.


Pediatrics_Nelson

Pediatrics_Nelson. Commonly there is no identified cause of enuresis and, in most cases, enuresis resolves by adolescence without treatment. Children with primary nocturnal enuresis are most likely to have a family history and are least likely to have an identified etiology. Children with secondary diurnal and nocturnal enuresis are more likely to have an organic etiology, such as UTI, diabetes mellitus, or diabetes insipidus, to explain their symptoms. Children with primary diurnal and nocturnal enuresis may have a neurodevelopmental condition or a problem with bladder function. Children with secondary nocturnal enuresis may have a psychosocial stressor or a sleep disturbance as a predisposing condition for enuresis.


Pediatrics_Nelson

Pediatrics_Nelson. Treatment begins with treating any diagnosed underlying organic causes of enuresis. Elimination of underlying chronic constipation is often curative. For a child whose enuresis is not associated with an identifiable disorder, all therapies must be considered in terms of cost in time, money, disruption to the family, the treatment’s known success rate, and the child’s likelihood to recover from the condition without treatment. The most commonly used treatment options are conditioning therapy and pharmacotherapy. The clinician can also assist the family in making a plan to help the child cope with this problem until it is resolved. Many children have to live with enuresis for months to years before a cure is achieved; a few children have symptoms into adulthood. A plan for handling wet garments and linens in a nonhumiliating and hygienic manner preserves the child’s self-esteem. The child should take as much responsibility as he or she is able, depending on age, development, and family


Pediatrics_Nelson

Pediatrics_Nelson. and linens in a nonhumiliating and hygienic manner preserves the child’s self-esteem. The child should take as much responsibility as he or she is able, depending on age, development, and family culture.


Pediatrics_Nelson

Pediatrics_Nelson. The most widely used conditioning therapy for nocturnal enuresis is the enuresis alarm. Enuresis alarms have an initial success rate of 70% with a relapse rate of 10%. The alarm is worn on the wrist or clipped onto the pajama and has a probe that is placed in the underpants or pajamas in front of the urethra. The alarm sounds when the first drop of urine contacts the probe. The child is instructed to get up and finish voiding in the bathroom when the alarm sounds. After 3 to 5 months, 70% of children are dry through the night.


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Pediatrics_Nelson. Pharmacotherapy for nighttime enuresis includes desmopressin acetate and, rarely, tricyclic antidepressants. Desmopressin decreases urine production and has proved to be safe in the treatment of enuresis. The oral medication is started at 0.2 mg per dose (one dose at bedtime) and on subsequent nights is increased to 0.4 mg and then to 0.6 mg if needed. This treatment must be considered symptomatic, not curative, and has a relapse rate of 90% when the medication is discontinued. Imipramine, now rarely used for enuresis, reduces the frequency of nighttime wetting. The initial success rate is 50%. Imipramine is effective during treatment only, with a relapse rate of 90% on discontinuation of the medication. The most important contraindication is risk of overdose (associated with fatal cardiac arrhythmia).


Pediatrics_Nelson

Pediatrics_Nelson. The psychological consequences can be severe. Families can minimize the impact on the child’s self-esteem by avoiding punitive approaches and ensuring that the child is competent to handle issues of their own comfort, hygiene, and aesthetics. Appropriate anticipatory guidance to educate parents that bed-wetting is common in early childhood helps alleviate considerable anxiety.


Pediatrics_Nelson

Pediatrics_Nelson. Constipation is decreased frequency of bowel movementsusually associated with a hard stool consistency. The occurrence of pain at defecation frequently accompanies constipation. Although underlying gastrointestinal, endocrinologic,or neurologic disorders can cause constipation, functional constipation implies that there is no identifiable causativeorganic condition. Encopresis is the regular, voluntary orinvoluntary passage of feces into a place other than the toilet after 4 years of age. Encopresis without constipation isuncommon and may be a symptom of oppositional defiantdisorder or other psychiatric illness. Soiling is the involuntarypassage of stool and often is associated with fecal impaction.The normal frequency of bowel movements declines betweenbirth and 4 years of age, beginning with greater than fourstools per day to approximately one per day.


Pediatrics_Nelson

Pediatrics_Nelson. The etiology of functional constipation and soiling includes a low-fiber diet, slow gastrointestinal transit time for neurologic or genetic reasons, and chronic withholding of bowel movements, usually because of past painful defecation experiences. Approximately 95% of children referred to a subspecialist for encopresis have no other underlying pathologic condition. In U.S. studies, 16% to 37% of children experience constipation between 5 and 12 years of age. Constipation with overflow soiling occurs in 1% to 2% of preschool children and 4% of school-age children. The incidence of constipation and soiling is equal in preschool girls and boys, whereas there is a male predominance during school age. Available @ StudentConsult.com


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Pediatrics_Nelson. Available @ StudentConsult.com The presenting complaint for constipation with soiling is typically a complaint of uncontrolled defecation in the underwear. Parents may report that the child has diarrhea because of soiling of liquid stool. Soiling may be frequent or continuous. On further questioning, the clinician learns that the child is passing large-caliber bowel movements that may occasionally block the toilet. Children younger than 3 years of age often present with painful defecation, impaction, and withholding. The history should include a complete review of systems for gastrointestinal, endocrine, and neurologic disorders and a developmental and psychosocial history.


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Pediatrics_Nelson. Stool impaction can be felt on abdominal examination in about 50% of patients at presentation. Firm packed stool in the rectum is highly predictive of fecal impaction. A rectal examination allows assessment of sphincter tone and size of the rectal vault. Evaluation of anal placement and existence of anal fissures also is helpful in considering etiology and severity. A neurologic examination, including lower extremity reflexes, anal wink, and cremasteric reflexes, may reveal underlying spinal cord abnormalities.


Pediatrics_Nelson

Pediatrics_Nelson. Abdominal x-ray is not required. It can be helpful to showto the family the degree of colonic distention and fecal impaction. In general further studies, such as barium enema andrectal biopsy, are indicated only if an organic cause for theconstipation is indicated by history or physical examination(see Chapter 129). Similarly although endocrinologic conditions such as hypothyroidism can cause chronic constipation,laboratory studies are not indicated without history or physicalexamination suggesting such a disorder.


Pediatrics_Nelson

Pediatrics_Nelson. The differential diagnosis for functional constipation and soiling includes organic causes of constipation (e.g., neurogenic, anatomic, endocrinologic, gastrointestinal, and pharmacologic). A child with chronic constipation and soiling who had delayed passage of meconium and has an empty rectum and tight sphincter may have Hirschsprung disease (see Chapter 129). Chronic constipation may be a presenting sign of spinal cord abnormalities, such as a spinal cord tumor or a tethered cord. Physical examination findings of altered lower extremity reflexes, absent anal wink, or a sacral hairy tuft or sacral sinus may be a clue to these anomalies. Hypothyroidism can present with chronic constipation and typically is accompanied by poor linear growth and bradycardia. Anal stenosis may lead to chronic constipation. The use of opiates, phenothiazine, antidepressants, and anticholinergics also may lead to chronic constipation. Developmental problems, including mental retardation and autism, may be


Pediatrics_Nelson

Pediatrics_Nelson. constipation. The use of opiates, phenothiazine, antidepressants, and anticholinergics also may lead to chronic constipation. Developmental problems, including mental retardation and autism, may be associated with chronic constipation.


Pediatrics_Nelson

Pediatrics_Nelson. Treatment begins with education and demystification forthe child and family about chronic constipation and soiling,emphasizing the chronic nature of this condition and the goodprognosis with optimal management. Explaining the physiologic basis of constipation and soiling to the child and the family alleviates blame and enlists cooperation. Education may improve adherence to the long-term treatment plan (Table 14-1). One half to two thirds of children with functional constipation recover completely and no longer require medication. Constipation affects 16% to 37% of children. 1% to 4% of children have functional constipation and soiling. Functional constipation with/without soiling begins early in life due to a combination of factors: Withholding of stool to avoid discomfort Use of medications that are constipating When chronic impaction, physiologic changes at the rectum reduce a child’s bowel control. Dilated rectal vault results in reduced sensation to standard fecal volume.


Pediatrics_Nelson

Pediatrics_Nelson. When chronic impaction, physiologic changes at the rectum reduce a child’s bowel control. Dilated rectal vault results in reduced sensation to standard fecal volume. Rehabilitation of rectal musculature and strength requires several months. Until then, dilated rectal musculature may be less able to expel stool effectively. Paradoxical anal sphincter contraction may occur when the urge to defecate is felt; it can lead to incomplete emptying of stool at defecation attempt. Many children do not recognize their soiling accidents owing to olfactory accommodation. Low self-esteem or other behavioral concerns are common on presentation. Improve for most with education and management for the constipation and soiling. Effective management of functional constipation requires a substantial commitment of the child/family, usually for 6–24 mo. Degree of child and family adherence is likely a predictor of the child’s success.


Pediatrics_Nelson

Pediatrics_Nelson. Degree of child and family adherence is likely a predictor of the child’s success. *The common features of the transition to the toddler diet (decreased fluid intake, continued high dairy intake, and finicky eating patterns) make this a high-risk time during development for constipation problems.


Pediatrics_Nelson

Pediatrics_Nelson. The younger the child is when diagnosis and treatment begin,the higher the success rate. Treatment involves a combination of behavioral training and laxative therapy. Successfultreatment requires 6 to 24 months. The next step is adequatecolonic cleanout or disimpaction. Clean-out methods includeenemas alone or combinations of enema, suppository, and orallaxatives. High-dose oral mineral oil is a slower approach toclean-out. Choice of disimpaction method depends on the ageof the child, family choice, and the clinician’s experience witha particular method. Methods and side effects are summarized in Table 14-2. The child and family should be includedin the process of choosing the clean-out method. Because enemas may be invasive and oral medication may be unpleasant,allowing points of choice and control for the child and praisingall signs of cooperation are important.


Pediatrics_Nelson

Pediatrics_Nelson. Behavioral training is essential to the treatment of chronic constipation and soiling. The child and family are asked tomonitor and document stool output. Routine toilet sitting isinstituted for 5 to 10 minutes three to four times per day. Thechild is asked to demonstrate proper toilet sitting position withthe upper body flexed forward slightly and feet on the floor Enema—6 mL/kg up to 4.5 oz (135 mL) If enemas are considered, administer first in physician’s office. Enema—6 mL/kg up to 4.5 oz (135 mL) every 12–24 h × 1–3 Invasive; risk of mechanical trauma Large impaction: mineral oil enema followed 1–3 h later by normal saline or phosphate enema Small impaction: normal saline or phosphate enema Normal saline Abdominal cramping; may not be as effective as hypertonic phosphate


Pediatrics_Nelson

Pediatrics_Nelson. Normal saline Abdominal cramping; may not be as effective as hypertonic phosphate Hypertonic phosphate Abdominal cramping; risk of hyperphosphatemia, hypokalemia, and hypocalcemia, especially with Hirschsprung or renal insufficiency or if retained. Some experts do not recommend phosphate enema for children <4 yr, others for children <2yr. Milk of molasses: 1:1 milk:molasses For difficult to clear impaction Combination: enema, suppository, oral laxative Day 1: Enema q12–24 h See enemas above Day 2: Bisacodyl suppository (10 mg) q12–24 h Abdominal cramping, diarrhea, hypokalemia Day 3: Bisacodyl tablet (5 mg) q12–24 h Abdominal cramping, diarrhea, hypokalemia Oral/nasogastric tube: Polyethylene glycol electrolyte solution Nausea, cramping, vomiting, bloating, aspiration. Large volume. Usually (GoLYTELY or NuLYTELY)—25 mL/kg/h up to 1000 mL/h × 4 h/day requires nasogastric tube and hospitalization to administer


Pediatrics_Nelson

Pediatrics_Nelson. Oral high-dose mineral oil—15–30 mL per year of age per day up Aspiration—lipoid pneumonia. Give chilled. to 8 oz × 3–4 days X-Prep (senna): 15 mL q12h × 3 Abdominal cramping. May not see output until dose 2 or 3 Magnesium citrate: 1 oz/yr of age to maximum of 10 oz per day for Hypermagnesemia 2–3 days or foot support. The child should be praised for all components of cooperation with this program, and punishment andembarrassment should be avoided. As symptoms resolve, toiletsitting is decreased to twice daily and finally to once a day.


Pediatrics_Nelson

Pediatrics_Nelson. When disimpaction is achieved, the child begins the maintenance phase of treatment. This phase promotes regular stool production and prevents reimpaction. It involves attention to diet, medications to promote stool regularity, and behavioral training. Increasing dietary fiber and fluid are recommended. For children with chronic constipation, the recommended daily dose of fiber is calculated as 10 grams plus the child’s age in years (e.g., a 10-year-old should take 20 grams of fiber per day). At least 2 oz of nondairy fluid intake per gram of fiber intake is recommended. Sorbitol-based juices, including prune, pear, and apple juice, increase the water content of bowel movements. Lubricants or osmotic laxatives are used to promote regular soft bowel movements. Maintenance medications, including side effects, are listed in Table 14-3. Polyethylene glycol powder is well tolerated because the taste and texture are palatable. Some children may require the use of a lubricant in addition to


Pediatrics_Nelson

Pediatrics_Nelson. side effects, are listed in Table 14-3. Polyethylene glycol powder is well tolerated because the taste and texture are palatable. Some children may require the use of a lubricant in addition to an osmotic laxative; children with severe constipation may require a stimulant laxative.


Pediatrics_Nelson

Pediatrics_Nelson. Treatment failure occurs in approximately one in five children secondary to problems with adherence or poor recognition of inadequate treatment resulting in reimpaction. Chronic constipation and soiling interfere with social functioning and self-esteem. Discomfort and fear of accidents may distract children from their schoolwork and other important tasks. Children also may develop unusual eating habits in response to chronic constipation and their beliefs about this condition. Case reports of child abuse related to soiling have been published. The primary care physician can recommend adequate fiber intake in all children and encourage families to help their children institute regular toileting habits at an early age as preventive measures. Earlier diagnosis of chronic constipation can prevent much secondary disability and shorten the length of treatment required. Juices containing sorbitol Pear, prune, apple Lactulose or sorbitol: 1–3 mL/kg/day ÷ doses bid See below


Pediatrics_Nelson

Pediatrics_Nelson. Juices containing sorbitol Pear, prune, apple Lactulose or sorbitol: 1–3 mL/kg/day ÷ doses bid See below Corn syrup (light or dark): 1–3 mL/kg/day doses bid Per Rectum Not considered risk for Clostridium botulinum spores Mineral oil: 1–3 mL/kg day as one dose or bid Aspiration—lipoid pneumonia Chill or give with juice Leakage: dose too high or impaction Osmotics Retain water in stool, aiding bulk and softness Lactulose: 10 g/15 mL, 1–3 cc/kg/day doses bid Synthetic disaccharide: abdominal cramping, flatus Magnesium hydroxide (milk of magnesia): Risk of hypermagnesemia, hypophosphatemia, secondary 400 mg/5 mL, 1–3 mL/kg/day bid hypocalcemia with overdose or renal insufficiency 800 mg/5 mL, 0.5 mL/kg bid MiraLAX (polyethylene glycol powder): Titrate dose at 3-day intervals to achieve mushy stool consistency 17 g/240 cc water or juice stock, 1.0 g/kg/day doses bid May make stock solutions to administer over 1–2 days (approximately 15 cc/kg/day)


Pediatrics_Nelson

Pediatrics_Nelson. Sorbitol: 1–3 mL/kg/day doses bid Less costly than lactulose Stimulants† Improve effectiveness of colonic and rectal muscle contractions Senna: syrup—8.8 g sennoside/5 mL Idiosyncratic hepatitis, melanosis coli, hypertrophic osteoarthropathy, analgesic nephropathy; abdominal cramping 2–6 yr: 2.5–7.5 cc/day doses bid 6–12 yr: 5–15 cc/day doses bid Improvement of melanosis coli after medication stopped (Tablets and granules available) Bisacodyl: 5-mg tablets, 1–3 tablets/dose 1–2 × daily Abdominal cramping, diarrhea, hypokalemia Bisacodyl: 10-mg suppositories, 0.5–1 suppository, 1–2 × daily Abdominal cramping, diarrhea, hypokalemia *Single agent may suffice to achieve daily, comfortable stools. †Stimulants should be reserved for short-term use.


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Pediatrics_Nelson. †Stimulants should be reserved for short-term use. Sleep is a universal phenomenon that is critical to child health, development, and daily functioning. This complex behavioral and physiologic process is characterized by a reversible state of partial unresponsiveness and disengagement from the environment. Sleep is broadly categorized by polysomnographic patterns into rapid eye movement (REM) sleep and non-REM (NREM) sleep. REM sleep is characterized by an active, awake-like electroencephalography (EEG) pattern and muscle atonia. NREM sleep is further divided into three stages—from stage 1 (N1), which is the lightest sleep stage and consists of low-amplitude, high-frequency EEG activity, to stage 3 (N3), also known as deep or slow-wave sleep, characterized by low-frequency, high-amplitude delta waves. REM and NREM sleep alternate in cycles throughout the night.


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Pediatrics_Nelson. Sleep architecture changes from fetal life through infancy and childhood. Sleep cycles last approximately 60 minutes in newborns and gradually lengthen to 90 minutes in children and adults. Neonates typically begin their sleep cycle in REM sleep, whereas older children and adults begin sleep in NREM sleep. REM sleep in neonates is termed active sleep, and frequent muscle twitches and facial grimaces are common. REM sleep comprises up to 50% of total sleep time in newborns and gradually decreases to 25% to 30% by adolescence. Slow-wave sleep is not seen before 3 to 6 months of age. Beginning from 6 to 12 months and continuing through adulthood, the amount of REM sleep shifts toward the last third of the night, while NREM sleep predominates during the first third of the night.


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Pediatrics_Nelson. The timing and duration of sleep also change with age. Sleep patterns become more diurnal and total daily sleep time gradually decreases. Full-term infants sleep on average 16 to 18 hours per day in fragmented intervals throughout the day and night. One-year-old children sleep on average 10 to 11 hours per night and nap for 2 to 3 hours during the day. Naps decrease from two naps to one during the second year of life. In the United States, over 80% of 2-year-olds nap, decreasing to 50% by age 3. By 12 years old, the average child sleeps 9 to 10 hours per day. By adolescence, the average sleep duration has dropped to 7½ hours per day, even though adolescents need an average of 9 hours per day. Adolescents also develop a physiologically based shift toward later sleep-onset and wake times relative to those in middle childhood.


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Pediatrics_Nelson. Cultural factors strongly influence multiple sleep practices, including whether children sleep independently (the norm in the United States) or with parents, other siblings, or grandparents (the norm in many other cultures). Awareness of the varying cultural practices regarding sleep is essential to respectful and effective intervention. Sleep problems are one of the most frequent complaints in pediatric practice. Numerous sleep disorders exist, including behavioral insomnias (bedtime refusal, delayed sleep onset, nighttime awakenings), parasomnias, and circadian rhythm disorders (Table 15-1). Obstructive sleep apnea (OSA) and sleep disorders associated with mental and physical illness should also be considered.


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Pediatrics_Nelson. Sleep problems occur in 20% to 30% of children at some pointduring childhood. Behavioral sleep disorders are common andfound across all age groups but are most prevalent from infancythrough preschool age. Bedtime resistance occurs in 10% to15% of toddlers, and 15% to 30% of preschool-aged children have difficulties achieving and/or maintaining sleep. Althoughgenerally benign, parasomnias occur commonly in young children, including sleep walking (15% to 40%) and sleep terrors(1% to 6%). OSA is reported in 1% to 4% of children. Circadianrhythm disorders occur in 7% to 16% of adolescents. Available @ StudentConsult.com


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Pediatrics_Nelson. Available @ StudentConsult.com Sleep disorders may manifest in a variety of ways and often go unrecognized. Some children present with daytime behavioral problems, including inattentiveness, hyperactivity, or irritability rather than overt sleepiness. Screening for sleep disorders is recommended as part of primary care. Clinicians should inquire about bedtime problems, excessive daytime sleepiness, wakenings during the night, regularity and duration of sleep, and presence of snoring and sleep-disordered breathing.


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Pediatrics_Nelson. The assessment of sleep complaints begins with a detailed history of sleep habits, including bedtime, sleep-onset, and wake times. A detailed description of the sleep environment can result in a dynamic understanding of the challenges to and resources for achieving normal sleep. The recommended history includes the type of bed, who shares it, the ambient light, noise, temperature, and the bedtime routine. Household structure, routines, and cultural practices may be important and influence the timing and ease of sleep (e.g., parental work patterns, evening activities, number of household members). Dietary practices influence sleep, including timing of meals and caffeine intake. A detailed history assessing for symptoms of OSA (gasps, snorting noises, breathing pauses, and so on) should be obtained in all children who snore regularly. New-onset sleep disorders may be associated with a psychological trauma. When the history does not reveal the cause of the sleep disorder, a sleep diary


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Pediatrics_Nelson. obtained in all children who snore regularly. New-onset sleep disorders may be associated with a psychological trauma. When the history does not reveal the cause of the sleep disorder, a sleep diary can be helpful.


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Pediatrics_Nelson. A complete physical examination is important to rule outmedical causes of sleep disturbance, such as conditions thatcause pain, neurologic conditions that could be associated withseizure disorder, and other central nervous system disorders.Children with genetic syndromes associated with developmental delay may have sleep disorders. Similarly children with attention-deficit/hyperactivity disorder and fetal alcohol syndromeare at higher risk for sleep disorders than other children. Carefulattention to the upper airway and pulmonary examination mayreveal enlarged tonsils or adenoids or other signs of obstruction.


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Pediatrics_Nelson. A polysomnogram is used to detect OSA, excessive limb movements, and seizure disorder. This consists of an all-night observation and recording performed in a sleep laboratory. Polysomnography is not indicated in children with primary insomnia (difficulty initiating or maintaining sleep), circadian rhythm disorders, uncomplicated parasomnias, or behaviorally based sleep problems.


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Pediatrics_Nelson. Behavioral insomnia of childhood is divided into two subtypes: Sleep-onset association subtype manifests as frequent orprolonged nighttime wakenings that occur in infants or youngchildren. During periods of normal brief arousal with each sleepcycle, the child awakens under conditions different from thoseexperienced as they fell asleep. Thus they are unable to return tosleep independently. Limit-setting subtype is most common in preschool-aged and older children and is characterized by bedtime resistance or refusal that stems from a caregiver’s unwillingness or inability to enforce bedtime rules and expectations.Nighttime fears are also common causes of bedtime refusal.


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Pediatrics_Nelson. Parasomnias include sleepwalking, sleep terrors, and confusional arousals. These occur during NREM sleep and are more likely during the first third of the night. They are most common in preschool children and are likely to resolve with time and developmental maturation. Sleepwalking is common and often benign but is sometimes associated with agitation or dangerous behaviors. Sleep terrors consist of an abrupt awakening with a loud scream, agitation, and unresponsiveness to caregivers’ attempts to console. Sleep terrors are differentiated Sleep-onset the night intervention Minimize nocturnal parental response association subtype Social disruptions Family stressors Night waking Regularize routines Refusal to sleep Family counseling Illness Any chronically irritating Painful crying out Treat disease symptomatically disorder (e.g., otitis, dermatitis, asthma, or esophageal reflux) DDAVP, 1-desamino-8-D-arginine vasopressin; OSA, obstructive sleep apnea.


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Pediatrics_Nelson. DDAVP, 1-desamino-8-D-arginine vasopressin; OSA, obstructive sleep apnea. from nightmares, which occur later in the night and result from arousal in REM or dreaming sleep. Children typically remember their nightmares but have no recollection of sleep terrors. Confusional arousals are similar to sleep terrors, tend to be less dramatic but last longer. Circadian rhythm disorders are most common during adolescence but can occur at any age. They consist of an exaggerated delayed sleep phase, leading to the inability to arouse in the mornings and failure to meet sleep requirements. Many adolescents attempt to recoup lost sleep on the weekends. The resulting sleep deprivation leads to problems with cognition and emotional regulation.


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Pediatrics_Nelson. Obstructive sleep apnea in childhood is not always obvious or easy to diagnose. OSA is commonly caused by tonsillar or adenoidal hypertrophy. A history of snoring is typical; some children may have excessive daytime sleepiness. Obese children are at increased risk for OSA. In toddlers OSA often is associated with poor growth, which improves when the obstruction is relieved by a tonsillectomy or adenoidectomy. Many children with OSA experience cognitive difficulties and school problems. Hyperactivity is also more common in these children than in age-matched controls. Primary sleep disorders must be differentiated from sleep disorders associated with psychiatric and medical disorders. Psychoses, anxiety disorders, and substance abuse can present with disordered sleep. The clinician should also consider sleep-related epilepsy and developmental disorders. Establishing a baseline of healthy sleep habits is essential toboth prevention and treatment of sleep disorders at all ages.


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Pediatrics_Nelson. Establishing a baseline of healthy sleep habits is essential toboth prevention and treatment of sleep disorders at all ages. Consistent bedtime routine (∼30 min) to cue sleep Consistent ambient noise, light, temperature in bedroom Adequate food, hydration, socialization, and physical activity during the day No television or other electronics in bedroom Avoidance of naps (unless developmentally appropriate) Child allowed to develop self-soothing strategies Parents are comfortable setting limits/boundaries


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Pediatrics_Nelson. Parents are comfortable setting limits/boundaries These include having a consistent and appropriate bedtime and bedtime routine, and close attention to sleep hygiene (seeTable 15-2). A bedtime routine should consist of three or foursoothing activities that help calm the child and signal that it istime for sleep. It should last no more than 30 minutes. Activities may include bathing, brushing teeth, reading a story, or singinga song. Even older children and adolescents require a consistent pre-bed routine. A transitional object such as a blanket orstuffed animal can be used to promote positive sleep associations and encourage self-soothing. The bedtime should be setearly enough to allow for sufficient nighttime sleep, and bothbedtime and morning wake time should be consistent, including on weekends. Televisions and other electronic devicesshould be removed from the bedroom because these can lead to delayed sleep onset and maladaptive sleep associations.


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Pediatrics_Nelson. Sleep-onset association disorder in infancy usually can beprevented by parental understanding of infant sleep physiology, developmentally appropriate expectations, and planningthe infant sleep environment to coincide with family needs.It is recommended that infants be put in bed drowsy, but stillawake, after they have had a diaper change, food, and comfort. Some toleration of infant crying is required for the infantto achieve self-regulation of sleep. A safe sleep environmentis essential. It is important for parents to understand that it isnormal for their infant to wake frequently for the first 6 weeksbefore settling into a routine of waking every 3 to 4 hoursfor feeding. Infants typically do not sleep through the nightbefore 6 months of age, and some do not sleep through thenight before 12 to 18 months of age. Even though co-sleeping(mother and infant sleeping together) is common, it is notrecommended because of increased risk of SIDS. Proactivelyconsidering the desirability of bed


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Pediatrics_Nelson. 12 to 18 months of age. Even though co-sleeping(mother and infant sleeping together) is common, it is notrecommended because of increased risk of SIDS. Proactivelyconsidering the desirability of bed sharing allows parents tobe in control rather than ceding control to the young child.


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Pediatrics_Nelson. Behavioral interventions comprise the mainstay of treatmentfor behavioral sleep disorders. In addition to meticulous attention to sleep hygiene and bedtime practices, difficulty fallingasleep and bedtime resistance in young children are treated byspecific behavioral strategies. Systematic ignoring consists of not responding to a child’s demands for parental attention at bedtime. Unmodified extinction (“cry it out”) involves putting thechild to bed and then ignoring the child’s demands until thenext morning. Graduated extinction involves waiting successively longer periods of time before briefly checking on the child.Both methods are effective in decreasing bedtime resistance andenabling young children to fall asleep independently. Positivereinforcement strategies can also be used in preschool-aged and older children. These include rewards (e.g., stickers) for meeting a bedtime goal (e.g., staying in bed). Rewards should beprovided immediately (first thing in the morning) to


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Pediatrics_Nelson. in preschool-aged and older children. These include rewards (e.g., stickers) for meeting a bedtime goal (e.g., staying in bed). Rewards should beprovided immediately (first thing in the morning) to increaseeffectiveness and better link the reward with the positive behavior. Children with nighttime fears can benefit from behavioraltherapy aimed at reinforcing feelings of safety.


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Pediatrics_Nelson. Infrequent or nonintrusive parasomnias do not need treatment beyond education and reassurance. Ensuring a safe environment is important. Sleep terrors are best managed by minimal intervention, because conversation with the child is impossible during the episode. Anticipatory brief awakening of the child shortly before the typical occurrence of a parasomnia may be effective in aborting the event. Children with frequent or prolonged parasomnias may need a sleep study to evaluate for possible coexisting sleep disorders or nocturnal seizures. Medications that suppress slow-wave sleep may be indicated in severe cases. Circadian rhythm disorders are also treated by ensuring sleephygiene practices and gradual resetting of the biologic clock.Bedtime fading involves allowing the child to go to bed at thetime he or she naturally feels tired, then gradually advancingthe bedtime forward over the course of several weeks.


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Pediatrics_Nelson. Rarely children with insomnia are treated pharmacologically. Melatonin (dose, 2.5 to 10 mg) has soporific properties useful in treating delayed sleep phase syndrome. It has been used successfully in both children with normal development and those with developmental delays. Melatonin is available without prescription in stores that sell dietary supplements. The α-agonist clonidine acts preferentially on presynaptic α2 neurons to inhibit noradrenergic activity. Somnolence is a side effect of clonidine, which can be put to use in cases of refractory sleep difficulties; this is an off-label use in children. Clonidine is usually started with a dose of 0.05 mg at bedtime and increased to 0.1 mg if needed. There are data on treating children as young as 4 years old with clonidine. Weaning offclonidine is recommended at the end of treatment.


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Pediatrics_Nelson. The most obvious and serious complication associated with childhood sleep disorders is impairment of cognitive ability and emotional regulation. This impairment puts children at risk for school failure, family difficulties, and social problems. It is likely that sleep-deprived children are at increased risk for acute illness and psychiatric disorders. Blass EM, Camp CA: Changing determinants of crying termination in 6to 12-week-old human infants, Dev Psychobiol 42:312–316, 2003 Glazener CM, Evans JH, Peto RE: Alarm interventions for nocturnal enuresis in children, Cochrane Database of Syst Rev(2): CD002911, 2005 Mindell JA, Owens JA: A Clinical Guide to Pediatric sleep: Diagnosis and Management of Sleep Problems, ed 2, Philadelphia, 2010, Lippincott Wil Potegal M, Davidson RJ: Temper tantrums in young children: 1. Behavioral composition. 2. Tantrum duration and temporal organization, J Dev Behav Pediatr 24:140–154, 2003


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Pediatrics_Nelson. Potegal M, Davidson RJ: Temper tantrums in young children: 1. Behavioral composition. 2. Tantrum duration and temporal organization, J Dev Behav Pediatr 24:140–154, 2003 Rubin G, Dale A: Chronic constipation in children, BMJ 333:1051–1055, Subcommittee on Attention-Deficit/Hyperactivity Disorder. Steering Com mittee on Quality Improvement and Management Wolraich M, Brown L, Brown RT, et al: ADHD: clinical practice guideline for the diagnosis, evaluation, and treatment of attention-deficit/hyperactivity disorder in children and adolescents, Pediatrics 128(5):1007–1022, 2011 SOMATOFORM DISORDERS, FACTITIOUS DISORDERS, AND MALINGERING


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Pediatrics_Nelson. SOMATOFORM DISORDERS, FACTITIOUS DISORDERS, AND MALINGERING The somatoform disorders are groups of disorders in which physical symptoms (pain or loss of function) are inconsistent and cannot be explained by a medical condition (Table 16-1).While transient symptoms, as “signals of distress,” are responsible for up to 50% of outpatient visits in the pediatric age group, somatoform disorders represent only the severe end of this continuum. Somatization that occurs in the context of a physical illness is identified by symptoms that go beyond the expected pathophysiology, affecting the child’s school, home life, and peer relationships and becoming the focus of the patient and the family’s life. Somatization is often associated with psychosocial stress and often persists beyond the acute stressor, leading to the belief by the child and the family that the correct medical diagnosis has not yet been found.


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Pediatrics_Nelson. A somatization disorder occurs in as many as 10% to 20% of first-degree relatives and has a higher concordance rate in monozygotic twin studies. Lifetime prevalence of somatoform disorders is 3%, and that of subclinical somatoform illness is as high as 10%. Adolescent girls tend to report nearly twice as many functional somatic symptoms as adolescent boys,whereas prior to puberty the ratio is equal. Affected children are more likely to have difficulty expressing emotional distress, come from families with a history of marital conflict, child maltreatment (including emotional, sexual, physical abuse), or history of physical illness. In early childhood, symptoms often include recurrent abdominal pain (RAP). Later headaches, neurologic symptoms, insomnia, and fatigue are more common.


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Pediatrics_Nelson. Explainable medical conditions and a somatoform disorder (e.g., seizures and pseudoseizures) can coexist in up to 50% of patients and present difficult diagnostic dilemmas. The list of systemic medical disorders that could present with unexplained physical symptoms includes chronic fatigue syndrome (CFS), multiple sclerosis, myasthenia gravis, endocrine disorders, chronic systemic infections, vocal cord dysfunction, periodic paralysis, acute intermittent porphyria, fibromyalgia, polymyositis, and other myopathies. Depression is a common comorbid condition and frequently precedes the somatic symptoms. Anxiety disorders can present with somatic complaints.


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Pediatrics_Nelson. Depression is a common comorbid condition and frequently precedes the somatic symptoms. Anxiety disorders can present with somatic complaints. DSM-IV classifies somatoform disorders as somatization disorder, undifferentiated somatoform disorder, somatoform disorder not otherwise specified, conversion disorder, pain disorder, body dysmorphic disorder (BDD), and hypochondriasis.The diagnostic criteria for somatoform disorders are establishedfor adults and need additional study in pediatric populations.


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Pediatrics_Nelson. Somatization disorder involves multiple unexplained physical complaints, including pain, gastrointestinal, sexual, and pseudoneurologic symptoms not caused by known mechanisms. The criteria used to diagnose this disorder are listed in Table 16-2. Given the requirement for at least one sexual or reproductive symptom, the diagnosis is unusual in children and the onset is common during adolescence. Prevalence estimates range from 0.2% to 2% in females and less than 0.2% in males. Early onset of somatization disorder is associated with poor prognosis. Undifferentiated somatoform disorder (Table 16-3)includes one or more unexplained physical complaints accompanied by functional impairment that last for at least 6 months. Children and adolescents are more likely to meet DSM-IV criteria for an undifferentiated somatoform disorder than for a somatization disorder, and no evidence exists to predict which patients will go on to develop the full symptom criteria for somatization disorder.


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Pediatrics_Nelson. Conversion disorder involves symptoms affecting voluntary motor or sensory function and is suggestive of a neurologic illness in the absence of a disease process (Table 16-4).Adjustment difficulties, recent family stress, unresolved grief reactions, and family psychopathology occur at a high frequency in conversion symptoms. A physical condition and a conversion disorder (e.g., epileptic and nonepileptic seizures) may coexist in the same patient. There are four subtypes of conversion disorder based on whether the symptoms presented are primarily motor, sensory, nonepileptic (seizures), or mixed. Presenting symptoms follow the psychological stressor by hours to weeks and may cause more distress for others than for the patient. This seeming lack of concern regarding potentially serious symptoms is referred to as la belle indifference.


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Pediatrics_Nelson. Presenting complaint is a physical symptom. Physical symptom is caused by a known physiologic mechanism. Physical symptom is stress induced. Patient may recognize association between symptom and stress. Symptom frequently responds to medication, biofeedback, and stress reduction. Presenting complaint is physical (loss of function, pain, or both). Physical symptom is not caused by a known physiologic mechanism. Physical symptom is related to unconscious idea, fantasy, or conflict. Patient does not recognize association between symptom and the unconscious. Symptom responds slowly to resolution of unconscious factors. Requires more than 13 physical symptoms in girls, more than 11 in boys (see Table 16-2) Physical symptoms are not caused by a known physiologic or pathologic mechanism. Physical symptoms are related to need to maintain the sick role. Patient convinced that symptoms are unrelated to psychological factors. Symptoms tend to persist or change character despite treatment.


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Pediatrics_Nelson. Patient convinced that symptoms are unrelated to psychological factors. Symptoms tend to persist or change character despite treatment. Presenting complaint is a physical sign or symptom. Patient interprets physical symptom to indicate disease. Conviction regarding illness may be related to depression or anxiety. Symptom does not respond to reassurance. Medication directed at underlying psychological problems often helps. Presenting complaint is a physical symptom. Physical symptom is under voluntary control. Physical symptom is used to gain reward (e.g., money, avoidance of military service). Patient consciously recognizes symptom as factitious. Symptom may not lessen when reward is attained (need to retain reward). Presenting complaint is symptom complex mimicking known syndrome. Symptom complex is under voluntary control. Symptom complex is used to attain medical treatment (including surgery).


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Pediatrics_Nelson. Presenting complaint is symptom complex mimicking known syndrome. Symptom complex is under voluntary control. Symptom complex is used to attain medical treatment (including surgery). Patient consciously recognizes symptom complex as factitious but is often psychologically disturbed so that unconscious factors also are operating. Symptom complex often results in multiple diagnoses and multiple operations. Each of the following criteria must be met. Individual symptoms may occur at any time during the course of disturbance. 1. Four pain symptoms: pain related to at least four different sites or functions (e.g., head, abdomen, back, joints, extremities, chest, rectum; during menstruation, sexual intercourse, or urination) 2. Two gastrointestinal symptoms: at least two gastrointestinal symptoms other than pain (e.g., nausea, bloating, vomiting, diarrhea, or intolerance of several foods) 3.


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Pediatrics_Nelson. Two gastrointestinal symptoms: at least two gastrointestinal symptoms other than pain (e.g., nausea, bloating, vomiting, diarrhea, or intolerance of several foods) 3. One sexual symptom: at least one sexual or reproductive symptom other than pain (e.g., sexual indifference, erectile or ejaculatory dysfunction, irregular menses, excessive menstrual bleeding, vomiting throughout pregnancy) 4. One pseudoneurologic symptom: at least one symptom or deficit suggesting a neurologic condition not limited to pain (conversion symptoms such as impaired coordination or balance, paralysis or localized weakness, difficulty swallowing or lump in throat, aphonia, urinary retention, hallucinations, loss of touch or pain sensation, double vision, blindness, deafness, seizures; dissociative symptoms such as amnesia; or loss of consciousness other than fainting) 1.


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Pediatrics_Nelson. After appropriate investigation, each of the symptoms is not fully explained by a known general medical condition or the direct effects of a substance (e.g., drug, medication). 2. When there is a related general medical condition, the physical complaints, social or occupational impairment are in excess of what is expected from the history, physical examination, or laboratory findings. A. One or more physical complaints (e.g., fatigue, loss of appetite, gastrointestinal complaints) B. Either (1) or (2) 1. After appropriate investigation, the symptoms cannot be fully explained by a known general medical condition or the direct effects of a substance (e.g., drug or medication). 2. When there is a related general medical condition, the physical complaints, social, or occupational impairment is in excess of what is expected from the history, physical examination, or laboratory findings.


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Pediatrics_Nelson. C. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. D. At least 6 months of disturbance E. The disturbance is not better accounted for by another mental disorder (e.g., another somatoform disorder, sexual dysfunction, mood disorder, anxiety disorder, sleep disorder, or psychotic disorder). F. The symptom is not intentionally produced or feigned (factitious disorder, malingering). Symptoms are often self-limited but may be associated with chronic sequelae, such as contractures or iatrogenic injury. Falling out syndrome (falling down with altered consciousness) is common in several cultures throughout the world, including the United States. Stocking glove (nonanatomic) anesthesia is another common finding. Symptoms are A. One or more symptoms affect voluntary motor or sensory function, suggesting a neurologic or other general medical condition.


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Pediatrics_Nelson. A. One or more symptoms affect voluntary motor or sensory function, suggesting a neurologic or other general medical condition. B. Psychological factors are judged to be associated with the symptom or deficit because the initiation or exacerbation is preceded by conflicts or other stressors. C. The symptom is not intentionally produced or feigned (factitious disorder, malingering). D. After appropriate investigation, the symptom cannot be fully explained by a general medical condition, by the direct effects of a substance, or as a culturally sanctioned behavior or experience. E. The symptom causes clinically significant distress or impairment in social, occupational, or other function or warrants medical evaluation. F. The symptom is not limited to pain or sexual dysfunction, does not occur exclusively during the course of somatization disorder, and is not better accounted for by another mental disorder.


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Pediatrics_Nelson. F. The symptom is not limited to pain or sexual dysfunction, does not occur exclusively during the course of somatization disorder, and is not better accounted for by another mental disorder. often inconsistent; patients may move a paralyzed extremity when they think that no one is watching. Nonepileptic seizures, sometimes described as pseudoseizures, resemble epileptic seizures but are not associated withthe electroencephalographic abnormalities or a clinical coursecharacteristic of true epilepsy. Most cases resolve within 3months of diagnosis. Referring to nonclassic presentations for seizures as spells can help avoid medicalization of these symptoms.


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Pediatrics_Nelson. The course of the condition is often benign, although20% to 25% of patients experience a recurrence. Goodprognostic characteristics include symptoms of paralysis, aphonia, blindness; acute onset; above-average intelligence; presence of an identifiable stressor; and earlydiagnosis and psychiatric treatment. Poor prognostic characteristics include tremor and pseudoseizures. The rate ofmisdiagnosis of conversion symptoms averages 4%. Myasthenia gravis, multiple sclerosis, dystonias, and dyskinesias(abnormal movements) are conditions commonly mistakenfor conversion disorder.


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Pediatrics_Nelson. Pain disorder is diagnosed instead of a conversion disorder if pain is the predominant physical symptom. The DSM-IV divides pain disorders into those associated with psychological factors, those with both psychological and medical factors, and those in which the medical condition is the major factor in the pain symptom (Table 16-5). The diagnosis is considered acute if the condition lasts less than 6 months and chronic when it lasts 6 months or more. RAP is the most common recurrent pain complaint of childhood and accounts for 2% to 4% of pediatric office visits. It is defined by intermittent pain with full recovery between episodes lasting more than 3 months. There is a strong relation between RAP and anxiety in children. Approximately 90% of pediatric patients have no clinical findings to account for their abdominal pain.


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Pediatrics_Nelson. Common types of headaches are migraine and tension-type headache. Migraine may be associated with dizziness, gastrointestinal symptoms, and cyclic vomiting syndrome, characterized by recurrent and stereotypic episodes of intense, A. Pain in one or more anatomic sites is the predominant focus and is of sufficient severity to warrant clinical attention. B. The pain causes clinically significant distress or impairment in social, occupational, or other important functions. C. Psychological factors have an important role in the onset, severity, exacerbation, or maintenance of the pain. D. The symptom or deficit is not intentionally produced or feigned (factitious disorder, malingering). E. The pain is not better accounted for by a mood, anxiety, or psychotic disorder and does not meet criteria for dyspareunia. Specify the following: Acute: duration <6 months


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Pediatrics_Nelson. E. The pain is not better accounted for by a mood, anxiety, or psychotic disorder and does not meet criteria for dyspareunia. Specify the following: Acute: duration <6 months Chronic: duration ≥6 months unexplained vomiting. Psychological factors frequently play a significant role in the complaint of a headache. Functional chest pain can be seen in 10% of school-aged children and adolescents. Other common pain disorders are musculoskeletal pains (limb pain and back pain), fibromyalgia, and complex regional pain syndrome type I (previously known as reflex sympathetic dystrophy). Reassurance is the primary treatment of pain disorder.Symptom diaries, including the events that precede and follow the pain episode, aid in initial assessment and ongoingmanagement of the problem. Minimizing secondary psychological consequences of recurrent pain syndromes isimportant.


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Pediatrics_Nelson. Hypochondriasis is the preoccupation with the fear ofhaving a serious disease based on misinterpretation of bodilysymptoms and functions. This fear should be present for6 months. The presenting complaint is a physical sign orsymptom, which is normal but is interpreted by the patientto indicate disease despite reassurance of a physician (e.g., atension headache perceived as a brain tumor). This diagnosisis more commonly seen in late adolescence and adulthood. An underlying depression or anxiety disorder may be relatedto the symptoms. Prevalence of obsessive-compulsive disorder (OCD) is four times greater than in the general population. When the belief or preoccupation is limited to animagined defect in appearance, the diagnosis is body dysmorphic disorder (BDD), not hypochondriasis.


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Pediatrics_Nelson. Body dysmorphic disorder is a preoccupation with animagined or slight defect in physical appearance that causesclinically significant distress or impairment in functioning. It is usually seen in adolescents (the male-to-femaleratio being almost equal) and is distinguished from common developmental preoccupations with appearance bythe presence of clinically significant distress and/or impairment in functioning. Any bodily area can be a focus, butexcessive concerns about the skin (scars and acne) and body shape are common. Because BDD can be associatedwith shame and the need for secrecy, the diagnosis may bemissed unless clinicians ask directly about symptoms. Parents of children with BDD report excessive mirror checking, grooming, attempts to camouflage a particular bodyarea, and reassurance-seeking. Patients may cause self-injury as a consequence of attempts to fix the perceived flaw.


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Pediatrics_Nelson. Many of these patients have had consultations with surgeons and dermatologists and often seek interventions butare unlikely to be satisfied with the results. BDD is considered to be related to OCD. The prevalence of BDD has been reported to be 0.7% in children, 2% in adolescents, and up to 5% in patients seeking cosmetic surgery. Many individuals with BDD report a history of childhood maltreatment; comorbid psychiatric disorders, including depression, OCD, social phobia, and anorexia nervosa; gender identity disorder; delusional disorder; and narcissistic personality disorder. BDD is also associated with high rates of suicidal ideation and attempts, with 28% of sufferers having attempted suicide.


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Pediatrics_Nelson. Fatigue is a common physical complaint, affecting up to50% of adolescents. CFS specifically refers to a conditioncharacterized by at least 6 months of severe, disabling fatigueassociated with self-reported limitations in concentration and short-term memory, sleep disturbance, and musculoskeletal aches and pains, where alternative medical andpsychiatric explanations have been excluded. CFS is oftenassociated with depression and can be incapacitating. CFS israre in childhood and uncommon in adolescence, with prevalence below 1%. Onset typically follows an acute post-viralillness in approximately two thirds of pediatric cases. Treatment is nonspecific, unless a psychological or general medical cause is uncovered.


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Pediatrics_Nelson. Screening tools for somatoform disorders include the Children’s Somatization Inventory (child and parent versions) and the Illness Attitude Scales and Soma Assessment Interview (parental interview questionnaires). The Functional Disability Inventory assesses the severity of symptoms. Treatment for somatoform disorders should use an integrated medical and psychiatric approach. The goals are to identify concurrent psychiatric disorders, rule out concurrent physical disorders, improve overall functioning, and minimize unnecessary invasive tests and doctor shopping. This works when mental health consultation is presented as part of a comprehensive evaluation, thereby minimizing stigma and distrust.


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Pediatrics_Nelson. Antidepressant medications (fluoxetine, sertraline, citalopram, and clomipramine) may be of benefit in the treatmentof unexplained headaches, fibromyalgia, BDD, somatoformpain, irritable bowel syndrome, and functional gastrointestinal disorders. Tricyclic antidepressants (clomipramineand others) should be avoided in youth with functional abdominal pain (FAP) because they have no proven efficacyin either pain management or mood disorders and are verydangerous in overdose. In chronic fatigue syndrome with comorbid depression and anxiety, a more activating antidepressant, like bupropion, can be useful. Stimulants may also be helpful in CFS.


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Pediatrics_Nelson. Cognitive-behavioral methods, which reward health-promoting behaviors and discourage disability and illness behaviors, help in the treatment of recurrent pain, CFS, fibromyalgia, and FAP. Interpersonal and expressive psychotherapies in the presence of psychological trauma are particularly useful. Self-management strategies, such as self-monitoring, relaxation, hypnosis, and biofeedback, provide some symptomatic relief and encourage more active coping strategies. Family therapy and family-based interventions can be very useful. Home schooling should be avoided, and school attendance and performance should be emphasized as important indicators of appropriate functioning. In dealing with pain symptoms (e.g., headaches, stomachaches) parents should remove or limit attention for pain behavior; strongly encourage sticking to schedule (e.g., going to school); help the child identify stress at home and school; provide attention and special activities on days when child does not have symptoms;


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Pediatrics_Nelson. strongly encourage sticking to schedule (e.g., going to school); help the child identify stress at home and school; provide attention and special activities on days when child does not have symptoms; and limit activities and interactions on sick days. Discussions about excessive discomfort or illness should be replaced with having the child practice relaxation techniques and educating personnel working with their child about these approaches.


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Pediatrics_Nelson. In contrast to somatoform disorders, patients intentionally simulate or create their problems in factitious disorders and malingering. Factitious disorder is a condition in which physical orpsychological symptoms are produced intentionally but forunconscious reasons to assume a sick role. This diagnosis is made either by direct observation or by eliminatingother possible causes. Most patients are immature, passive,and hypochondriacal. They show improvement when confronted with their behavior or acknowledge the factitiousnature of their symptoms. It has been associated with borderline personality traits and substance abuse disorders.Approximate answers (e.g., 20−3=13) reported during amental status examination are most commonly found infactitious disorders.


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Pediatrics_Nelson. Munchausen syndrome by proxy (MBP) is a form of factitious disorder by proxy, where a parent (usually mother) mimics symptoms in his or her child. The motivation is believed to be a psychological need to assume a sick role through the child. Of these mothers, more than 72% have a history of factitious disorder or a somatoform disorder, and up to 80% of involved parents have some health care background. MBP is a type of child abuse. Boys are more commonly abused in this way, and neonates and preschoolers are the most common victims. Both factitious disorder by proxy (diagnosis of the abuser) and pediatric condition falsification (diagnosis of the child) are needed for diagnosis.


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Pediatrics_Nelson. Common presenting symptoms include vomiting, diarrhea,respiratory arrest, asthma, seizures, incoordination, fever, bleeding, failure to thrive, rash, hypoglycemia, and loss of consciousness. Simulation of psychiatric disorders is rare. Nearly 75% of the morbidity to the child occurs in hospitals from invasive procedures. Once confronted with negative test results or discharge planning, the perpetrators may become intensely enraged and acutely suicidal or may initiate legal action so the treatment team should take appropriate precautions. Mortality in MBP may be as high as 33%, and siblings of these children are also at risk. Virtually all children suffer serious psychological sequelae from this form of abuse. Treatment involves protecting the child from further abuse and reporting to child protective services.


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Pediatrics_Nelson. Malingering is a condition in which a physical symptom that is under voluntary control is used to gain reward (e.g., money or avoidance of school, jail, or obtaining drugs). The patient has conscious intent in production of symptoms. Symptoms may not lessen when the reward is attained. Malingering is difficult to prove unless the patient is directly observed or confesses. Anxiety disorders are characterized by uneasiness, excessive rumination, and apprehension about the future. The conditions tend to be chronic, recurring, and vary in intensity over time. They affect 5% to 10% of children and adolescents (Table 17-1). Some common anxiety disorders are discussed in the following sections.


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Pediatrics_Nelson. Panic disorder is the presence of recurrent, unexpected panic attacks. A panic attack is a sudden unexpected onsetof intense fear associated with a feeling of impending doomin the absence of real danger. At least 1 month of persistentworrying about having another panic attack is required tomake the diagnosis (Table 17-2). Panic disorder most oftenbegins in adolescence or early adulthood. Symptom severitywaxes and wanes. Characteristic symptoms include shortnessof breath, palpitations, chest pain, a choking or smothering sensation, and a fear of losing control or going “crazy” (Table 17-3). Symptoms generally last approximately 15 minutes andare generally time-limited. It is common for patients to thinkthat they are about to die of a heart attack. Panic attacks areclassified as (1) spontaneous, (2) bound to situations (occurimmediately on exposure), and (3) predisposed to situations(attacks occur while at school, but not every time). Agoraphobia is a condition describing fear of


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Pediatrics_Nelson. (2) bound to situations (occurimmediately on exposure), and (3) predisposed to situations(attacks occur while at school, but not every time). Agoraphobia is a condition describing fear of situations where escapeis difficult or would draw unwanted attention to the person.Agoraphobia is often persistent and can leave people homebound. Panic disorder is seen in 95% of patients with agoraphobia. The condition is more common in females. Considerthe diagnosis of a specific phobia (as opposed to agoraphobia)if the avoidance is limited to one or a few specific situationsor social phobia if avoidance is limited to social situations ingeneral.


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Pediatrics_Nelson. Generalized anxiety disorder (GAD) is characterized by 6or more months of persistent, out of proportion worry and anxiety that includes a historical diagnosis of overanxious disorderof childhood. The worries should be multiple, not paroxysmal,and not focused on a single theme and should cause significantimpairment (Table 17-4).The anxiety must be accompanied byat least three of the following symptoms: restlessness, easy fatigability, difficulty concentrating, irritability, muscle tension,and disturbed sleep. Physical signs of anxiety are often present, Epidemiology Prevalence is 0.2%−10%; rates are similar in all racial groups. Half have agoraphobia. Eight times more common and of early onset in family members of affected individuals than general population. Prevalence is 5%. The Prevalence is around sex ratio is equal. 8%. Twin studies Genetic factors play suggest some genetic only a modest role in role. the etiology.


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Pediatrics_Nelson. Prevalence is 5%. The Prevalence is around sex ratio is equal. 8%. Twin studies Genetic factors play suggest some genetic only a modest role in role. the etiology. Prevalence is 2%−4% of children and adolescents. The sex ratio is almost equal. Heritability of SAD is greater for girls than for boys. Prevalence is 2%. Sex ratio is 2:1 females:males. Increased risk of specific phobias in first-degree relatives of patients with specific phobias. Onset Average age at onset is The average age at The average age at 15–19 years; earlier in 25%. onset is 10 years. onset is 8–9 years. Differential Anxiety disorder due to a diagnosis general medical condition. Substance-induced anxiety disorder due to caffeine or other stimulants. ADHD, Attention-deficit/hyperactivity disorder; PTSD, posttraumatic stress disorder. A. Both (1) and (2) 1. 2. At least one attack is followed by ≥1 month of one or more of the following: a. b.


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Pediatrics_Nelson. ADHD, Attention-deficit/hyperactivity disorder; PTSD, posttraumatic stress disorder. A. Both (1) and (2) 1. 2. At least one attack is followed by ≥1 month of one or more of the following: a. b. Worry about the implications of the attack or its consequences (e.g., losing control, having a heart attack, “going crazy”) c. A significant change in behavior related to the attacks B. The presence of agoraphobia C. The panic attacks are not due to direct physiologic effects of drugs or abuse or medication or a general medical condition (e.g., hyperthyroidism). D. The panic attacks are not better accounted for by another mental disorder, such as social phobia, specific phobia, obsessive-compulsive disorder, posttraumatic stress disorder, or separation anxiety disorder. A discrete period of intense fear or discomfort, in which four or more of the following symptoms developed abruptly and reached a peak within 10 minutes: Palpitations, pounding heart, or accelerated heart rate


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Pediatrics_Nelson. Palpitations, pounding heart, or accelerated heart rate Sensations of shortness of breath or smothering Feeling of choking Feeling dizzy, unsteady, lightheaded, or faint


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Pediatrics_Nelson. Derealization (feelings of unreality) or depersonalization (being detached from oneself) Fear of losing control or going crazy Paresthesias (numbness or tingling sensations) Chills or hot flashes including shakiness, trembling, and myalgias. Gastrointestinalsymptoms (nausea, vomiting, diarrhea) and autonomic symptoms (tachycardia, shortness of breath) commonly coexist. Inchildren and adolescents, the specific symptoms of autonomicarousal are less prominent, and symptoms are often related toschool performance or sports. Children with GAD are oftenexceedingly self-conscious, exhibit behavioral inhibition, havelow self-esteem, and have more sleep disturbance than patientswith other kinds of anxiety disorder. Care must be taken to elicit internalizing symptoms of negative cognitions aboutthe self (hopelessness, helplessness, worthlessness, suicidalideation), as well as those concerning relationships (embarrassment, self-consciousness) and associated with anxieties.Inquiry about eating,


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Pediatrics_Nelson. self (hopelessness, helplessness, worthlessness, suicidalideation), as well as those concerning relationships (embarrassment, self-consciousness) and associated with anxieties.Inquiry about eating, weight, energy, and interests should alsobe carried out to eliminate a mood disorder.


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Pediatrics_Nelson. Posttraumatic stress disorder (PTSD) is characterized by re-experiencing a traumatic event in which actual or threatened death or serious injury was possible. The reexperiencing Criteria for Diagnosis of Generalized Anxiety Disorder A. Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6 months, about numerous events or activities B. The person finds it difficult to control the worry. C. The anxiety and worry are associated with three or more of the following six symptoms (with at least some symptoms present for more days than not for the past 6 months). Note: Only one symptom is required in children. 1. 2. 3. 4. 5. 6. Sleep disturbance (difficulty falling or staying asleep or restless, unsatisfying sleep)


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Pediatrics_Nelson. 1. 2. 3. 4. 5. 6. Sleep disturbance (difficulty falling or staying asleep or restless, unsatisfying sleep) D. The focus of the anxiety and worry is not confined to features of a disorder (e.g., panic disorder, social phobia, obsessive-compulsive disorder, separation anxiety disorder, anorexia nervosa, somatization disorder, hypochondriasis), and the anxiety and worry do not occur exclusively during posttraumatic stress disorder. E. The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. F. The disturbance is not due to the direct physiologic effects of a drug or a general medical condition (e.g., hyperthyroidism) and does not occur exclusively during a mood disorder, a psychotic disorder, or a pervasive developmental disorder.


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Pediatrics_Nelson. is accompanied by avoidance of stimuli that remind the person of the trauma and by autonomic hyperarousal (Table 17-5). Type, severity, duration, and proximity of the traumatic event are the most likely predictors of PTSD. Presentation often depends on the age group of the child. In preverbal children, there are changes in behavior: regressed clingy behavior, increased aggression, unwillingness to explore the environment, alterations in feeding, sleeping behaviors, and difficulty soothing child. Preschool children may display rapidly changing emotional states like anger, sadness, and excitement and play may have compulsive reenactments linked to the traumatic event. Later symptomatology is more typical of adult PTSD, except that flashbacks are more daydream quality than the sudden intrusive events seen in adults, and complaint of restriction of effect and numbing are less frequent.


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Pediatrics_Nelson. Dissociative states lasting a few seconds to many hours, in which the person relives the traumatic event, are referred to as flashbacks. Reexperiencing trauma in children may be nonspecific to the trauma (e.g., dreams of monsters). In adolescents anticipation of unwanted visual imagery increases the risk of irritable mood, anger, and voluntary sleep deprivation. When faced with reminders of the original trauma, physical signs of anxiety or increased arousal occur, including difficulty falling or staying asleep, hypervigilance, exaggerated startle response, irritability, angry outbursts, and difficulty concentrating. Typically an acute stress disorder is present immediately after the trauma. The risk of chronic PTSD increases when symptoms are unresolved by 6 weeks and there are higher premorbid levels of anxiety or depression. PTSD usually begins A. The person has been exposed to a traumatic event in which both of the following were present: 1.


Pediatrics_Nelson

Pediatrics_Nelson. A. The person has been exposed to a traumatic event in which both of the following were present: 1. The person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury or a threat to the physical integrity of self or others. 2. The person’s response involved intense fear, helplessness, or horror. Note: In children, this may be expressed instead by disorganized or agitated behavior. B. The traumatic event is persistently reexperienced in one or more of the following ways: 1. Recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions. Note: In young children, repetitive play may occur in which themes or aspects of the trauma are expressed. 2. Recurrent distressing dreams of the event. Note: In children, there may be frightening dreams without recognizable content. 3.


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Pediatrics_Nelson. 2. Recurrent distressing dreams of the event. Note: In children, there may be frightening dreams without recognizable content. 3. Acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations, and dissociative flashback episodes, including flashbacks that occur on awakening or when intoxicated). Note: In young children, trauma-specific re-enactment may occur. 4. Intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event. 5. Physiologic reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event. C. Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by three or more of the following: 1. Efforts to avoid thoughts, feelings, or conversations associated with the trauma 2.


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Pediatrics_Nelson. Efforts to avoid thoughts, feelings, or conversations associated with the trauma 2. Efforts to avoid activities, places, or people that arouse recollections of the trauma 3. Inability to recall an important aspect of the trauma 4. 5. Feeling of detachment or estrangement from others 6. Restricted range of affect (e.g., unable to have loving feelings) 7. Sense of a foreshortened future (e.g., does not expect to have a career, marriage, children, or a normal life span) D. Persistent symptoms of increased arousal (not present before the trauma), as indicated by two or more of the following: 1. 2. Irritability or outbursts of anger 3. 4. 5. E. Duration of the disturbance (symptoms in criteria B, C, and D) is >1 month F. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning Specify the following: Acute: if duration of symptoms is <3 months Chronic: if duration of symptoms is ≥3 months


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Pediatrics_Nelson. Specify the following: Acute: if duration of symptoms is <3 months Chronic: if duration of symptoms is ≥3 months With delayed onset: if onset of symptoms is at least 6 mo after the stressor within 3 months of the trauma, although delay in symptom expression can occur. Rates of suicide attempts are threefold higher than unaffected controls. Acute stress disorder is characterized by the same signs and symptoms as PTSD but occurs immediately after a traumatic event. If impaired function persists after 1 month, the diagnosis is PTSD. Anxiety disorder not otherwise specified is a common condition in clinical practice. This diagnosis is used when there is impairing anxiety or phobic symptoms that do not meet full criteria for another anxiety disorder.


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Pediatrics_Nelson. Separation anxiety disorder (SAD) is seen in childrenand adolescents who express vague somatic symptoms (e.g.,headaches, abdominal pain, fatigue) to avoid or refuse togo to school. Patients may have a valid or an irrational concern about a parent or have had an unpleasant experience inschool. They often have been seen by numerous specialistsand have undergone elaborate medical evaluations. Theirabsence from school often is mistakenly seen as a consequence of their symptoms. The prospect of returning toschool provokes extreme anxiety and escalating symptoms.True phobia related to schoolwork is rare. SAD is a strong(78%) risk factor for developing problems in adulthood, suchas panic disorder, agoraphobia, and depression. School phobia that first presents during adolescence may be an expression of a severe underlying psychopathologic condition.Psychiatric consultation is needed.


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Pediatrics_Nelson. Specific phobias are marked persistent fears of things or situations, which often lead to avoidance behaviors (Table 17-6). The associated anxiety is almost always felt immediately when the person is confronted with the feared object or situation. The greater the proximity or the more difficult it is to escape, the higher the anxiety. Many patients have had actual fearful experiences with the object or situation (traumatic event). The response to the fear can range from limited symptoms of anxiety to full panic attacks. Children may not recognize that their fears are out of proportion to the circumstances, unlike adolescents and adults, and express their anxiety as crying, tantrums, freezing, or clinging.


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Pediatrics_Nelson. School phobia is one of a range of reasons for school nonattendance. In severely worried children, defensive aggression may be used to prevent attendance. Otherwise these patients do not have antisocial tendencies. Boys and girls are equally affected and there is no association with social class, intelligence, or academic ability. The youngest in a family of several children is more likely to be affected as well as children of older parents. Truancy is generally associated with older adolescents with lower levels of fear. Unlike anxious school refusers, truants hide their school nonattendance from their parents. Social phobia is a common (3% to 13% prevalence; girls predominate over boys) type of phobia characterized by a marked and persistent fear of social or performance situations in which embarrassment might occur (Table 17-7).


Pediatrics_Nelson

Pediatrics_Nelson. There is a wariness of strangers and social apprehension or anxiety when encountering new, strange, or socially threatening situations. Children appear to have a lower rate of negative cognitions (e.g., embarrassment, overconcern, self-consciousness) than adults. Children with simple avoidant disorders are younger than those with more socialized phobic conditions. Left untreated or poorly treated, phobias can become immobilizing and result in significant morbidity and restriction of their lives. A. Marked and persistent fear that is excessive or unreasonable, cued by the presence or anticipation of a specific object or situation (e.g., flying, heights, animals, receiving an injection, seeing blood) B. Exposure to the phobic stimulus almost invariably provokes an immediate anxiety response, which may take the form of a situationally bound or situationally predisposed panic attack. Note: In children, the anxiety may be expressed by crying, tantrums, freezing, or clinging.


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Pediatrics_Nelson. C. The person recognizes that the fear is excessive or unreasonable. Note: In children, this feature may be absent. D. The phobic situation is avoided or else is endured with intense anxiety or distress. E. The avoidance, anxious anticipation, or distress in the feared situation interferes significantly with the person’s normal routine, occupational (or academic) functioning, or social activities or relationships, or there is marked distress about having the phobia. F. In children <18 years, the duration is at least 6 months. G. The anxiety, panic attacks, or phobic avoidance associated with the specific object or situation are not better accounted for by another mental disorder, such as obsessive-compulsive disorder, posttraumatic stress disorder, separation anxiety disorder, social phobia, panic disorder with agoraphobia, or agoraphobia without history of panic disorder. Specify type: Animal type is fear elicited by animals or insects.


Pediatrics_Nelson

Pediatrics_Nelson. Specify type: Animal type is fear elicited by animals or insects. Natural environment type (e.g., heights, storms, water). Blood/injection/injury type is fear related to seeing blood, injuries, injections, or having an invasive medical procedure. Situational type is fear caused by specific situations (e.g., airplanes, elevators, enclosed places). Other type (e.g., fear of choking, vomiting, or contracting an illness; in children, fear of loud sounds or costumed characters)