2025 – PAGE 439 – PSYCHIATRY AND SOME SOCIAL ISSUES

FOSTER CARE

Child welfare agencies’ caseworkers are responsible for coordinating the healthcare needs of foster children. Pediatricians assist the child welfare caseworkers in accessing appropriate health services. All children should have an initial health assessment within 72 hours of placement into foster care and have a full comprehensive evaluation within 30 days of placement.

PEARL: The foster parents do not make medical decisions for the child. That is the role of the birth parents/guardian at the time of removal. The child welfare agency should provide a copy of that consent to the medical home. So, to give vaccines at a well-child check, the consent must be in the child’s EMR.

PEARL: The foster care agency should incorporate the results of comprehensive assessment into the child’s court-approved social service case plan.

PARENTAL ADJUSTMENT TO A CHILD WITH MALFORMATIONS

Parents need to adjust to a child with malformations. They may initially not want to hold, see, or feed the baby. Pediatricians are responsible for encouraging bonding. The classic stages are as follows: Shock/Fear → Denial → Sadness/Anger → Acceptance.

CHRONICALLY ILL FAMILY MEMBER

Children may have trouble coping with the idea of having a chronically ill member of the family. Protective factors include having financial security in the home, being male (girls try to act like mothers), younger age, and having a large, complete (not divorced), and joyful home.

CONVERSION DISORDER

Conversion disorder is an unintentional NEUROLOGIC complaint often after a stressful or traumatic event (unilateral extremity paralysis, loss of vision, etc.). It usually resolves within 1–2 days.

PEARL: This is not a fake complaint. It’s usually ACUTE.

SOMATIZATION

Somatization is an unintentional complaint (not necessarily neurologic). In children, this usually presents in the form of headaches and abdominal pain. This is sometimes considered to be a child’s way of “taking control” of uncontrollable and stressful situations.

PEARL: This can be a chronic complaint or problem. Again, it’s not fake.

PSYCHOSOMATIC

Psychosomatic exacerbation is a true exacerbation of a chronic medical illness due to stress. The symptoms subside fairly quickly, even if the stress does not. An example of this would be a true exacerbation of eczema due to a stressful life event.

BREATH-HOLDING SPELLS

Breath-holding spells are most common between 6 to 18 months of age. Children have apneic episodes in response to pain, fear, anger, frustration, or injury. Children can become unconscious or even have a seizure with a postictal period. EEG is always normal. No specific treatment is required except making sure that children don’t hurt themselves during a seizure.

PEARL: Patients do not have to pass out for it to be called a breath-holding spell. Children stop having them by about 5 years of age (usually much earlier).

• CYANOTIC BREATH-HOLDING SPELLS: These are the most common. Anger or frustration seem to be the primary triggers, though the trigger can vary. Usually, children will cry so hard that at the end of expiration they turn blue, lose muscle tone, and then become unconscious. They usually wake up 1–2 minutes later.
• PALLID BREATH-HOLDING SPELLS: These are more commonly due to pain, fear, or an injury. Children become pale and then lose consciousness.
  • MNEMONIC: “You look like you saw a ghost!” That’s a phrase commonly used to describe people when they suddenly become afraid and become pale. Think of pallid breath-holding spellsthe same way. Uncontrollable factors cause a spell, whereas cyanotic breath-holding spells seem to have more to do with difficulty controlling emotions.