Neurological and Mental Health Problems in - Myilstuedu home.rtf by shensengvf


									                                                                 NUR 471 Neuro and Mental Health 1

                       NUR 471 Family Nurse Practitioner I
                                   Spring 2012
                Neurological and Mental Health Problems in Children
Common Problems
    A. Cerebral palsy
    B. Developmental delays and mental retardation
           1. Micro/macroencephalopathy
           2. Craniosynotosis
           3. Down Syndrome
    C. Spina bifida
    D. Seizure disorders
    E. Febrile seizures
    F. Meningitis
    G. Brain lesions
    H. Reye’s syndrome
    I. Hypotonia: Muscular Dystrophy
    J. Headaches
    L. Depression/suicide
    M. Anxiety (added)
    N. Bullying
    O. Autism
    P. Sleep Disorders

Associated Readings:
       Burns et al. (2009). Pediatric Primary Care. Read Chapters 15, 16, 27, 1125-1133.
       Chiocca. (2011). Advanced Pediatric Assessment. Read Chapters 22 & 24.
       Hay et al. (2011). Current Diagnosis & Treatment Pediatrics. Read Chapters 6 (171-182,
       common disorders listed above) & 23 (696-706, common disorders listed above).

Optional resource on neurological exam of newborns with videos!

Cerebral Palsy
   Non-progressive disorder of movement
   Caused by injury to the CNS
   Incidence: 1-3 live birth per 1000
   Brain lesion is static but manifestation changes over several years due to developing nervous system
   Mental retardation 26% (mild), 27% (severe)
   Microcephalic
   Definitive diagnosis of cerebral palsy should not be made until 1 year of age (changing findings)

Diagnosis- based on 4 out 6 major motor areas:
 Posture
 Oral motor functioning
 Visual-motor functioning
                                                                 NUR 471 Neuro and Mental Health 2

   Tone
   Evolution of primitive reflexes
   Muscle-stretch reflexes; hyperreflexia

Levine (Poster) Criteria for Diagnosing Cerebral Palsy
 P –posturing and abnormal movement pattern
 O – oropharyngeal problems
 S – strabismus
 T – tone, increased or decreased in muscles
 E – evolution response, persistent primitive reflexes/ failure to develop protective response
 R – reflexes, deep tendon reflex increase, plantar reflexes up-going

Types of Cerebral Palsy
 Hemiparesis
 Spastic Diplegia/ Quadriplegia; 75%
 Dystonic-Athetoid (Extrapyramidal)
 Hypotonic
 Ataxic; 15%
 Mixed

Management Issues in CP
 Nutrition (FTT common due to oral motor problems) - assess/educate parents re: eating difficulties/
  appropriate techniques
 Constipation – common (stool softeners/ regular bowel regime)
 Drooling – skin breakdown/ social issue
 Seizures – 50%
 Orthopedic issues – muscle relaxants
 Safety issues – high risk for injury
 Multi-disciplinary management

 Average head circumference at birth: 2 cm greater than chest circumference (about 35cm)
 Head growth faster in premature infants than term infants
 Microcephaly – 2 standard deviations below the mean (or 2nd percentile for age and gender)
 Macrocephaly – 2 standard deviation above the mean
 Refers to brain size

Causes of Micro/Macrocephaly
 Infections
 Drugs
 Anoxia
 Heredity
 Chromosomal
 Malformations
 Trauma
 Perinatal metabolic/endocrine imbalances
 Malnutrition
 Perinatal maternal illness
                                                                 NUR 471 Neuro and Mental Health 3

Microcephaly – no treatments or medications are indicated
 Counseling for parents
 Genetic evaluation and counseling
 Routine follow-up with neurologist

Macrocephaly – dependent on cause
 Monitor for ICP and immediately seek medical attention - teach parents to monitor
      o Infants – bulging fontanels, vomiting, drowsiness, seizures
      o Older child - headache, blurred vision, behavior changes, decreased level of consciousness,
          vomiting, seizures)
 Monitor head circumference (document parent’s head circumference) and fontanel size
 Chromosomal evaluation

 Premature fusion of the cranial sutures, usually beginning in utero
 Sagittal suture most common (50%)
 More common in boys
 Results in skull/craniofacial deformities
 Increased intercranial pressure
 Cause – chromosomal or unknown etiology
 Goal is to ensure normal brain growth
 Surgery is usually treatment of choice

Down Syndrome
 Common chromosomal abnormality; 1/800 to 1/1000 live births
 Involves multiple anomalies due to partial or complete (84%) trisomy of chromosome 21
 Prenatal diagnosis by amniocentesis offered to women over 35 years
 Most born to women under age 35
 Genetic counseling and chromosome analysis of parents (especially with translocation of 21)
 Interdisciplinary team management is key

Diagnostic Features
    Facial; up-slanted palpebral fissures, small nose with low nasal bridge, inner epicanthal folds, flat
       facial profile, Brushfield spots (speckling of iris), open mouth, tongue protruding, small ears
    Flat occiput
    Short neck, excess skin on posterior neck
    Hypotonia
    Hyper-flexibility of joints
    Limbs; wide space between first and second toe, single palmar crease, short wide hands
    Small stature, immature gait

Associated Developmental and Medical problems
    Variable global delay
    Mid-moderate mental retardation (IQ 45-90)
    40-60% with cardiac problems – ASD, VSD, TOF, PDA
    12% with GI problems – Hirschsprung Disease, imperforate anus, duodenal atresia
    Jaundice when newborn
                                                               NUR 471 Neuro and Mental Health 4

       Orthopedic problems – atlantoaxial instability, late hip dislocation
       Ophthalmologic problems – refractive errors, myopia, congenital cataracts, strabismus
       ↑ incidence of OM, chronic sinusitis, hearing loss (70-80%), hypothyroidism, leukemia

Management considerations
    Medical – through physical evaluation
         o Consider X-rays if indicated for orthopedic problems, echocardiogram, TSH, vision and
             hearing screening
    Educational – IEP, teacher’s aide in classroom
    Psychological – social skills training, behavioral therapy consult

Spina Bifida and Myelomeningocele
 Most frequent serious congenital malformation
 Multifactorial cause (incidence 1 in 1000 live births)
 Folic acid supplementation is protective
 Neural tube defect – present at birth
 Level of lesion in spinal cord determines child’s potential for mobility
 75% of lesions occur in lumbosacral area
 Scoliosis develops with higher level lesions
 Foot deformities occur early due to ↓innervation of ankle dorsiflexors and weak plantar flexors

Care Issues with Spina Bifida
 Monitor growth & development
 Skin breakdown due to decreased sensation
 Safety – prone to injury due to w/c or braces and decreased mobility
 Bowel and bladder management – assess bladder program; constipation is common and can cause
   shunt malfunction or UTIs
 Latex allergy is common in those with spina bifida
 Multidisciplinary management

Seizure Disorder
 Definition: Abnormal brain functioning caused by abrupt, uncontrolled, repetitive discharges of
    cortical neurons with the brain
 Incidence: Approximately 3.5 to 5% of children have a seizure by 15 years of age
 Only 1% with seizures have epilepsy (recurrent seizures)
 50% occur in children under 10 years
 Appx. ½ of childhood seizures are idiopathic

Common Etiology
 Neonate: hypoxia, CNS bleed, infection
 Infants: infection, dehydration, fever, CNS trauma, inborn errors of metabolism
 Children and Adolescent: head trauma, fever, tumor, toxin ingestion, non-adherence or inadequate
   dose of anticonvulsant med, street drugs esp. cocaine, breath-holding spells

Classification of Seizures:
Generalized Seizures (arise from both cerebral hemispheres)
    Nonconvulsive
            o Typical absence seizures – petit mal
            o Atypical absence seizures – onset gradual
                                                                  NUR 471 Neuro and Mental Health 5

        Convulsive
             o Tonic – abrupt increase in muscle tone
             o Atonic – abrupt decrease in muscle tone
             o Clonic – repetitive muscle jerking
             o Tonic-Clonic – classic grand mal seizure
             o Myoclonic – brief, shock-like muscle contractions
Partial Seizures (focal onset)
     Simple – does not impair consciousness
            o Symptoms bases on lobe affected such as temporal (emotional sensations, smell,
              taste), frontal (strange movements), parietal (strange sensations), occipital (visual
       Complex – focal onset seizure that does involve the loss or impairment of consciousness
       Both types of partial seizures may present with motor signs (clonic jerking), sensory symptoms
        (tingling, distortions of smell or vision), autonomic signs (pallor, diaphoresis), or psychic sxs
        (fear, hallucinations)
Status epilepticus: Prolonged seizure for > 30 minutes

     High-risk screening by 5 questions: Born prematurely, family history of seizures, personal history
        of seizures, head injury with loss of consciousness for 30 minutes or more, CNS infection
        (meningitis, encephalitis)
     Characteristics of seizure
     Loss of consciousness
     Presence of an aura; visual, auditory, sensations
     Abnormal eye movements
     Precipitating events
     Post-ictal state
     Head injury
     Incontinence
     Cyanosis
     Hx of seizures, medication, underlying illness

    Complete physical/neurologic exam
    Blood chemistry (serum glucose, lytes, Ca, BUN, CBC with diff)
    Lead screen
    Toxicology on blood and urine in teens
    Liver function tests
    EEG; may need to do serial EEGs (sleep-deprived)
    MRI (for focal seizures, adolescent with 1st seizure)
    Don’t routinely change from Trade to Generic brand drug; increase risk of seizure
    Referral/consultation
         o May not treat 1st seizure
         o Some seizures in children resolve with aging
         o Trial off medication if > 5 years seizure free
         o No driving until 6 months seizure fee

   Routine monitoring of lab related to anticonvulsant medications (levels, CBC, LFTs as indicated)
                                                                 NUR 471 Neuro and Mental Health 6

       Dental hygiene/gum hyperplasia if on Dilantin
       Emphasize need to never abruptly discontinue meds
       Educate regarding seizure precautions and safety issues (ie. shower versus bath, no swimming
        alone, biking, mowing, pregnancy)

Febrile Seizures
    Occurs in approximately 2% of children; most common childhood seizure
    Highest incidence between 6-18 months (range 3 months-5 years)
    Risk increases with:
            o Family hx of seizures
            o Maternal smoking during pregnancy
            o Prematurity
            o Day care > 20 hours per week
            o Frequent infections in the 1st year of life
    Triggered by rapid rise in temperature to at least 39 degrees during the early course of an illness
    A febrile seizure that occurs after the 1st 24 hours of fever is most likely due to significant
    Most are generalized seizures (tonic-clonic)
    Duration: 50% last < 5 minutes; 75 % last < 20 minutes; 2-3% last longer than 30 minutes
       Recurrence risk 30%, < 1year-old 50%
       Increased risk of epilepsy

    Controlling fever (rectal acetaminophen, sponging)
    Monitoring for any sign of meningitis esp in children under 2 yrs
    Monitoring for other infections (UTIs, throat) with UA, CBC, strep screen
    Lorazepam used for status epilepticus due to less resp. depression
    Prophylaxis with anticonvulsant if: family member has hx of nonfebrile seizures; duration > 15
      min; > 1 seizure in 24 hrs; prior hx of abnormal neuro exam
    Reassure parents/of nature of seizures
    Seizure precaution education
    Referral if uncertain of diagnosis or cause of recurrence

   Most common pathogens: Strep pneumoniae and Neisseria meningitidis (2 mo to 12 yrs)
   Aseptic meningitis (acute inflammation of meninges) most often viral
   Incidence: increased during winter and spring
   More common in males/age 2 mos to 2 years
   Risk factors: varicella inf., URI, insect bites, without Hib or MMR vaccinations, head trauma,
   Sxs: irritability, fever, lethargy, nuchal rigidity, confusion, severe headache

Brain Lesions
    Most common brain tumors:
           o Astrocytoma
           o Medullablastoma
           o Ependymoma
    2nd most common childhood malignancy
    Incidence: 3 per 100,000 under 15yrs
                                                               NUR 471 Neuro and Mental Health 7

      Sxs: headaches, neuromuscular changes, behavioral changes, vomiting, seizures, papilledema
       cranial neuropathy, VS changes

Care of children with brain tumors
    Txs: surgery, chemotherapy, radiation
    Monitor nutrition
    Immunizations
    Sleep
    Safety
    Vision/hearing/dental screening
    Discipline – advise parents to use other strategies than spanking
    Normal activity as possible

Reye’s Syndrome
    Encephalopathy and non-inflammatory fatty infiltration of liver and kidney
    Associated with epidemics of influenza A & B, and chicken pox and medicating with aspirin for
       viral illness (predisposes to developing Reye’s syndrome)
    Sxs: protracted vomiting; confusion; combative behavior; agitation; stupor; coma
    Management: supportive care, monitoring ICP, vit K or fresh frozen plasma, educate parents
       regarding no aspirin products

Muscular Dystrophy
   Duchenne and Becker Muscular dystrophy (most common types) - genetically determined
   Progressive disorder affecting muscles of upper extremities, chest wall and heart
   Clinical onset: appx 3 yrs old, with rapid progression
   Sxs: hx of clumsiness; trips and falls easily; muscular looking calves; delayed motor
      development; inability to keep up with peers when running, mental impairment (30%), scoliosis
      -Gower maneuver - pushes off one’s own upper legs to get up from seated position

Optional resource Migraine headache article
      Majority of HAs due to nonorganic causes (Tension, allergies, sinus infections, migraines 5-15%)
      Frequent complaint; 37% by age 7, 69% by age 14
      More common in girls
      Young children (less than 5 years of age) esp with specific complaints are likely to have organic
      Increased risk: stressful home/school environments; family hx of HA; parent with mental health
       problem; recent major life crisis; use of drugs or ETOH
      Hx/Exam:
           o Ask about associated sxs
           o Vital signs (esp temp and B/P)
           o Complete Neurologic exam
           o Assessment of TMJ/dental exam
           o Visual acuity/last vision exam by optometrist
           o Thorough HEENT exam
           o Skin inspection for rashes and/or lesions

Headache Warning Signs – Indicators of Organic Etiology
    New onset (less than 3 months)
                                                                NUR 471 Neuro and Mental Health 8

       Child less than 3 years old
       Headaches associated with diplopia/papilledema
       Awakens child in middle of night, worse when lying down
       Pain present upon arising but improves as day progresses, or occipital pain (common with
       Bruit in temporal areas
       Positive neurologic finding/seizures/N/V
       Increase in frequency/severity over a few weeks
       Exacerbated by position changes, straining, coughing
       Petechiae/ecchymosis
       Post trauma

Headache Differential Dx:
    Acute generalized: fever, infection; trauma
    Acute localized: sinusitis, otitis, dental, TMJ, cocaine use
    Acute recurrent: migraine, cluster, post seizure
    Chronic progressive: tumor, brain abscess, subdural, hematoma, hemorrhage, vasculitis
    Chronic nonprogressive (tension headache): muscle contraction, malingering, post concussion,
       depression, anxiety, adjustment reaction

    Medicate at onset of headache. Reassurance is important.
    Headache diary if frequent, including diet.
    Acetaminophen: if sxs infrequent or not severe (15mg/kg/dose) for non-migraine
    Acute migraine attacks
         o Ibuprofen: when acetaminophen not providing good relief or if migraine or menses
             related HA (5-10mg/kg/dose) q 6-8 hrs
         o Abortive for migraines (if has aura): sumatriptan po 50 mg children 6-12 yrs; 100mg if
             over 12 yrs
    Migraine Prophylaxis
         o Beta-blockers, propranolol 40-80 mg BID initially
         o Sleep
         o Stress reduction
         o Dietary management
    With comorbid depression - Zoloft 50 mg per day
    Also used but not recommended in migraine clinical guideline;
         o Fiorinal (butalbital, aspirin, caffeine) 1-2 caps q 4 hrs if ibuprofen not effective, use
             sparingly (for adolescents)
         o Amitriptyline (for adolescents) 25-50mg q HS

ADHD - Attention Deficit Hyperactivity Disorder (ADHD and ADD)
 Most commonly diagnosed behavioral problem
     o Is it under-diagnosed or over-diagnosed?
        o Does every inattentive child have ADD or ADHD?
   One of five most common chronic disorders of childhood
   Prevalence for school age children 3-5%; 4.5 million 5 to 17 year-olds
   3 Basic Symptoms of ADHD
        o Inattention (pays attention too many things),
        o Impulsivity,
                                                               NUR 471 Neuro and Mental Health 9

       o Hyperactivity
   M>F
      o    Teachers expect more of boys
       o Boys more hyperactive/impulsive so diagnosed earlier
       o Girls more inattention so often diagnosed in Middle school
   Clear genetic influences (twin studies), believed to be due to;
        o Low norepinephrine (inattention, distractability) and,
        o Low dopamine (impulsivity, behavior problems).
   Clear environmental influences; maternal tobacco&/or alcohol use, fetal distress, low birth weight
   Big controversy due to increased use of stimulants in 1990’s
   80% have comorbid conditions; ODD (35%), OCD CD (30-50%), mood disorders (15-70%), anxiety
    disorders (25%), substance abuse, and may precede development of Tourette’s
   2011 AAP guidelines cover age 4-18

ADHD – Hyperactive/Impulsive Criteria
 Fidgets hands or feet or squirms in seat
 Leaves seat in classroom
 Runs about or climbs excessively
 Difficulty playing quietly
 “On the go” or “driven by a motor”
 Talks excessively
 Blurts out answers
 Difficulty waiting turn
 Interrupts or intrudes on others

ADHD Inattentive Criteria
 Makes careless mistakes
 Difficulty sustaining attention
 Does not seem to listen
 Does not follow through
 Difficulty organizing tasks
 Avoids tasks that require mental effort
 Loses necessary items
 Easily distracted
 Forgetful

ADHD evaluation
 Symptoms before age 7; difficult to diagnose before age 4
 DSM IV criteria
     o Symptoms present for at least 6 months
       o   ≥ 2 settings (home, daycare, school, work)
       o   Evidence of social, academic &/or occupational impairment
       o   At least 6 inattention symptoms and/or hyperactivity/impulsivity symptoms
       o   Some hyperactivity/impulsivity symptoms must have been present before 7 years-old
   Symptoms are not better accounted for by another mental illness
   Information must be obtained directly from parent and teachers (Conner’s)
   History; DSM-IV criteria, family history
                                                               NUR 471 Neuro and Mental Health 10

   Physical exam; complete history, growth, neurological, auditory/visual screening
   Consider testing; CBC, lead, TSH, neurodevelopmental, psychoeducational
   Differential diagnosis: see Burns pg. 328

Treatment for ADHD
     Behavioral (positive reinforcement, time-out, token economy, response cost) 1st line
     Medication, 2nd line starting at age 4
           o Stimulants: methylphenidate (Ritalin), methylphenidate extended release (Concerta,
               Ritalin SR, Metadate ER, Methylin), amphetamine/dextroamphetamine (Adderall)
           o Non-stimulant: atomoxetine (Strattera), Pemoline, Guanfecine, clonidine (for aggression,
               tics, controversial for sleep problems- off label, need baseline ECG, important SEs &
           o If one stimulant does not work at the highest feasible dose, try another
           o Parent education on side effects crucial
     Dietary considerations; monitor weight
     Close follow-up is important for successful management including input of school (family
       support, nutrition, sleep, academic performance, psychological functioning)

Depression and Suicide
 Rate of depression increases with age; 1-3% before puberty, 8% adolescent, nearly adult rate by at 15
   (lifetime risk 10-25% women; 5-12% men)
 Depression rate higher for females starting at puberty 5:1, equal rate before puberty
 50% do not seek treatment
 Most treated in primary care
 Often comorbid with ADHD, conduct disorders, anxiety disorders, eating disorders, substance abuse
 Suicide is the 2nd leading cause of death for 15-19 year olds
        o For each suicide, approximately 100-200 attempts
        o Medical examiners under report 25-50%
        o 1 in 5 (19%) high school students consider attempting suicide

Behavioral Warning Signs
 Changes in appetite or weight
 Changes in behavior
 Changes in school performance
 Helplessness/Hopelessness
 Loss of energy
 Loss of interest in activities/withdrawal
 Morbid ideation
 Substance abuse

Myths of Youth Suicide
 Most youth suicides occur unexpectedly without warning signs
 Youth who talk about suicide do not attempt or commit suicide
 Most youth who try suicide fully intend to die
 Educating youth about suicide leads to increased suicide attempts
 Many suicide threats or attempts should not be taken seriously
 Youth suicide occurs only among poor individuals
 Only a counselor can help a suicidal youth
                                                                 NUR 471 Neuro and Mental Health 11

How can primary providers help prevent suicide?
    General screening includes:
           o Pt/Fam hx of psychiatric disorders
           o Pt/Fam hx of previous suicide attempts
           o Hx of substance abuse
           o Brief mental status exam
    Ask directly about suicidal ideation, physical and sexual abuse
    Actively listen to patient
    Know your referral options!
           o Treatment usually psychotherapy and in moderate to severe depression medication

Anxiety Disorders
 Prevalence – Social Anxiety Disorder (3-13%), Generalized Anxiety Disorder (3-8&), Panic Disorder
   (6%), Obsessive Compulsive Disorder (2-4%), Phobias (2-9%); others with unknown prevalence
   include Separation Anxiety Disorder, PTSD, Selective Mutism
 Illness of secrecy – need to ask about especially in quiet patient
 Course - onset frequently in childhood, ½ recover, chronic & untreated anxiety in childhood increases
   adult risk 2-3X, leads to depression and alcoholism in adulthood
 Differential diagnosis – endocrine, infectious, neurological, drug/toxim, psychosis, affective,
 Often co-morbid with depression, ADHD, other anxiety disorders
 SSRIs best studied, TCAs and BZ also used
 CBT works
 Clinical practice guidelines -
 Resources –,,

    Physical, verbal, relational, electronic (triad of bully, bullied, bystander)

Autism Spectrum Disorders (ASD)
Optional resources Autism Training Program
       Epidemiology – Prevalence is 1 in 110 in U.S. (CDC, 2009), M>F 4-5:1, 10-25% with
        identified etiology
       Developmental screening at 9, 18 & 30 months important – early warning signs!
       ASD includes Autistic Disorder (AD), Rett Disorder, Childhood Disintegrative Disorder,
        Asperger’s Disorder, Pervasive Developmental Disorder Not Otherwise Specified (PDD-
       ASD Core Deficits (deviant relative to developmental level)
            o Socialization – giving, showing, social smiles, gestures, eye contact
            o Communication – absent spoken language and/or imaginative play
            o Repetitive/stereotypic behavior – rigidity, routines, perseverations
       Sensory integration dysfunction (visual, auditory, tactile, gustatory, olfactory)
       Average age of diagnosis > 3 years for AD, > 4 years with PDD, > 5 years for Asperger’s
       Medical evaluation should include – dysmorphology exam, TSH, lead level, CMP (AA,
        hypoglycemia), EEG, MRI
                                                               NUR 471 Neuro and Mental Health 12

      Clinical evaluations and therapy (if indicated) should include – hearing, speech/language,
       occupational, sensory, psychological
      Earlier behavioral intervention beneficial with low risk of harm
           o Address specific difficulties such as speech with best evidence therapy
      Pharmacology may be useful in management of selected symptoms, significant adverse
       effects-should be prescribed by providers with high volume of ASDs.
           o   Atypical psychotics may be useful with aberrant behaviors (reserve aggression or risk of
               self-injury), SEs
           o   SSRIs no benefit with repetitive behaviors
          o Secretin not useful
      Disturbed sleep may be due to serotonin (high anxiety, fear and arousal) & dopamine
       abnormalities (muscle twitching ), late and low Melatonin release, circadian rhythm
      Educational plan and family support key

Common Sleep Disorders
   Significant impact on physical, emotional and educational development

Common sleep disorders by age
  • Infant – confusional arousals, insomnia, sleep-disordered breathing (SDB-sleep apnea
     and others).
  • Preschool – sleep terrors, nightmares, sleep enuresis, insomnia, restless legs syndrome
     (RLS), periodic limb movement disorder (PLMD), SDB.
  • Grade school – sleep walking, nightmares, sleep enuresis, insomnia, RLS, PLMD, SDB.
  • Adolescent – insomnia, RLS, PLMD, SDB , delayed sleep phase syndrome, narcolepsy.

As part of a well visit screen use BEARS:
   • Bedtime problems,
   • Excessive daytime sleepiness,
   • Awakenings during the night,
   • Regularity and duration of sleep,
   • Sleep disordered breathing.

Optional resource – PowerPoint presentation on children and sleep.

To top