Pediatric Primary Care (133 page)

2.  Nightmares: frightening dreams that awake the child and make the child afraid to return to sleep; usually occurs during the last third of the sleep cycle during REM sleep.

3.  Appears frightened; pupils dilated.

4.  Tachycardia, hyperventilation.

5.  Thrashing of extremities.

6.   Inconsolable, not aware of parents' presence.

7.  Panic.

8.  Sleepwalking.

9.  Returns to sleep.

10.  No recall of night terror in morning.

D.  Physical findings.

A.  None.

E.  Diagnostic tests.

A.  None necessary.

F.  Differential diagnosis.

1.  Rule out emotional disorder; anxiety; depression.

2.  Seizures.

G.  Treatment.

1.  Child should be encouraged to lie down and be helped back to sleep (e.g., talking quietly, rubbing back).

2.  Turn on light or use a nightlight in the bedroom.

3.  Encourage family to wake child before episode for 1-2 weeks to attempt to break cycle.

4.  Protect child from injury.

5.  Prepare babysitter for possible episode.

6.  Leave bedroom door open.

7.  Provide comfort, reassurance to child.

8.  Counseling may be necessary for children who have severe nighttime fears.

H.  Follow up.

1.  Refer to psychologist or psychiatrist if night terrors or nightmares persist.

2.  Complete family evaluation may be necessary.

I.  Complications.

Night terrors, 307.46

1.  Injury.

2.  Continued nighttime fears.

J.  Education.

1.  Often night terrors are self-limiting.

2.  Family support may be necessary to reduce parental anxiety.

VI.  SCHOOL REFUSAL

A.  School-refusal behavior refers to any refusal to attend school or difficulty attending classes for an entire day by a child.

B.  Occurrence.

1.  5-28% of youths.

2.  Prevalence: fairly equivalent among gender, racial, and economic status.

C.  Triggers for school refusal.

1.  Dysfunctional family patterns.

2.  Impending school changes.

3.  Illness.

4.  Traumatic experiences.

D.  Clinical manifestations.

1.  Range of behaviors.

2.  Depression.

3.  Social anxiety.

4.  Fears.

5.  Fatigue.

6.  Somatic complaints.

7.  Noncompliance.

8.  Aggression.

9.  Clinging.

10.  Temper tantrums.

11.  Run away from home.

E.  Physical findings.

1.  No physical exam findings.

2.  Mental health assessment may reveal comorbid mental health problems.

F.  Diagnostic tests and assessment tools.

1.  Consider drug and alcohol screening based on presenting history.

2.  Consider pregnancy testing and screening for sexually transmitted disease if history of runaway.

3.  Anxiety Disorders Interview Schedule for DSM-IV (Parent and Child versions).

4.  The School Refusal Assessment Scale-Revised (SRAS-R).

G.  Treatment.

1.  Determine who will conduct the interventions: refer to school psychologist, social worker.

2.  Cognitive behavioral therapy.

3.  Relaxation therapy.

4.  Problem solving skills instruction.

5.  Parent interventions.

6.  Morning and evening routines.

H.  Education.

1.  Instructions for parents on effective parenting skills.

I.  Follow up.

1.  Monitor progress weekly and then monthly until problem resolves.

BIBLIOGRAPHY

Agency for Health Care Policy and Research.
Diagnosis of attention deficit/hyperactivity disorder
[Technical Review No. 3]. Rockville, MD: U.S. Department of Health and Human Services; 1999.

American Psychiatric Association.
Diagnostic and statistical manual of mental disorders, IV-TR
Washington, DC: Author; 2000.

Burns CE, Dunn AM, Brady MA, Starr NB, & Blosser CG.
Pediatric primary care.
4th ed. St. Louis, MO: Saunders; 2009.

Conners CK. ADHD therapy: Optimizing functional outcomes.
Contemporary Pediatrics.
2003;20(Suppl):4-6.

Dube SR, & Orpinas P. Understanding excessive school absenteeism as school refusal behavior.
Children and Schools.
2009;31:87-95.

Forbes F. Improving recognition and management of ADHD.
Practitioner.
2010;254(1728):34 -38.

Kearnery CA, & Bates M. Addressing school refusal behavior: Suggestions for frontline professionals.
Children and Schools.
2005;27:207-216.

Liu YH, & Leslie LK. Diagnosing ADHD: Putting AAP guidelines to the test–and into practice.
Contemporary Pediatrics.
2003;20:51-73.

Melnyk BM, & Moldenhauer Z., eds. The KySS (keep your children/yourself safe and secure): Guide to child and adolescent mental health screening, early intervention and health promotion. National Association of Pediatric Nurse Practitioners and NAPNAP Foundation; 2006.

Salmeron PA. Childhood and adolescent attention-deficit hyperactivity disorder: Diagnosis, clinical practice guidelines, and social implications.
Journal of the American Academy of Nurse Practitioners.
2009;21: 488-497.

Stein MT, & Perrin JM. Diagnosis and treatment of ADHD in school-age children in primary care settings: A synopsis of the AAP practice guidelines.
Pediatrics in Review.
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Wolraich ML. ADHD therapy: Optimizing functional outcomes.
Contemporary Pediatrics
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CHAPTER 35

Mental Health Disorders

Kim Walton and Susan J. Kersey

I.  ANXIETY DISORDERS

A.  Presentation of anxiety disorder; includes both physical and emotional characteristics.

B.  Etiology.

1.  Biochemical changes in brain.

a.  Possible genetic vulnerability.

b.  Post-traumatic stress disorder (PTSD) present in children who survive severe or terrifying physical or emotional event. Also occurs when witnessing an event that the child perceives as threatening; this includes domestic violence.

c.  Separation anxiety, note relative frequency in children of mothers with panic disorder.

C.  Occurrence.

1.  Most common mental illness group occurring in children and adolescents.

2.  Estimated prevalence of any anxiety disorder among children and adolescents is 13% in 6-month period.

D.  Clinical manifestations.

1.  Generalized anxiety disorder (also known as overanxious disorder in children).

a.  Characterized by at least 6 months of persistent, excessive anxiety/ worry over everyday events; difficult to control the worry.

b.  Anxiety and worry are associated with at least one of following: