Chapter 27: PSYCHIATRY AND SOME SOCIAL ISSUES

ATTENTION DEFICIT DISORDER (AKA ADD, ADHD, and ATTENTION DEFICIT HYPERACTIVE DISORDER)

Impulsive + Inattentive + Disorganized thoughts in a child = Attention deficit disorder (AKA ADD and ADHD). This must be DIAGNOSED AFTER 4 years of age, but symptoms must be PRESENT prior to 12 years of age. ADD is more common in boys than in girls. Fifty percent persist into adulthood, especially the inattentive/disorganized part. Sugar doesn’t exacerbate it. The best treatment is pharmacologic + “other” interventions (psych referral).

PEARLS: If a child was started on a stimulant medication and now pays more attention, that does not diagnose ADD. Before making the diagnosis, make sure lead poisoning, iron deficiency, vision problems, hearing problems, thyroid disorders, sedating medications (antihistamines, seizure medications), CNS infection, and CNS trauma have been ruled out. Other conditions to consider include hay fever, Klinefelter Syndrome, absence seizures, maternal drug/alcohol abuse, patient drug/alcohol abuse, and depression.

LEARNING DISABILITIES

Learning disabilities are usually discovered in older children when school gets harder. Patients with learning disabilities have problems in specific areas (math, reading, writing, speaking, listening, or reasoning). Learning disabilities can be overcome with training, but they are not outgrown.

PEARLS: A difference in the Verbal IQ and the Performance IQ (spatial/visual skills) means the child is at risk for a learning disability. Letter reversal is normal until 7 years of age. After that, it is a sign of dyslexia. Stuttering is okay until about 4 years of age. It is also ok for a child to go back and forth between periods of fluency and disfluency. If the stutter persists into school age, do a workup including an evaluation by a speech-language pathologist.

MNEMONIC: All of a child’s language should be intelligible by 4 years of age, so a stutter should be gone by then too!

SCHOOL PHOBIA

School phobias tends to occur in single-parent households. Treat by having the parent escort the child to school, have the child spend more time with peers, and decrease the amount of time being spent with the parent.

DEATH RESPONSE IN CHILDREN

• CLASSIC STAGES OF THE DEATH RESPONSE: Shock/paralysis → Denial/avoidance → Anger/‌Resentment/‌Outpouring of emotions → Bargaining → Depression/Realization → Testing/looking for realistic solutions → Acceptance. Having said that, in children the response often depends on the age groups they are in.
  • PRESCHOOL: Regression ± tantrums.
  • SCHOOL AGE: Trouble at school, trouble sleeping, possible physical complaints/somatization (headaches, abdominal pain).
  • TEENAGERS: Acting out.
• PEARL: If you get a question about death and what to do as a pediatrician, choosing reassurance will be wrong! Choose something to do that is benign (not medications).