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 K. ADD/ADHD 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! http://library.med.utah.edu/pedineurologicexam/html/newborn_n.html#01 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 Micro/Macrocephaly 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 Management: 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 Craniosynotosis 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 sensations) 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 History 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 Management 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 Monitoring/Education 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 infection 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 Management 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 Meningitis 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, day-care 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 Headaches Optional resource Migraine headache article http://www.aafp.org/afp/2009/1215/p1445.html 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 etiology 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 tumors) 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 Management 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 http://pediatrics.aappublications.org/content/128/5/1007.full.pdf+html 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 & Contraindications). 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, ADHD/ADD Often co-morbid with depression, ADHD, other anxiety disorders SSRIs best studied, TCAs and BZ also used CBT works Clinical practice guidelines - http://www.aacap.org/cs/root/member_information/practice_information/practice_parameters/practice _parameters Resources – www.childanxiety.net/, www.adaa.org/, www.aacap.org/. Bullying Physical, verbal, relational, electronic (triad of bully, bullied, bystander) Autism Spectrum Disorders (ASD) Optional resources Autism Training Program http://www.cdc.gov/ncbddd/actearly/act/class.html 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- NOS) 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 disorder 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 dysynchrony 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.
Pages to are hidden for
"Neurological and Mental Health Problems in - Myilstuedu home.rtf"Please download to view full document