Pediatric Primary Care (134 page)

•  Restlessness.

•  Being easily fatigued.

•  Difficulty concentrating.

•  Irritability.

•  Muscle tension.

•  Sleep disturbance.

c.  Symptoms must cause significant distress or impairment in functioning.

2.  Obsessive compulsive disorder (OCD).

a.  Obsessions: recurring thoughts or images that are disturbing, intrusive, cannot be controlled through rational reasoning.

•  Common obsessions:

i.  Contamination.

ii.  Fear of harm to self/family member.

iii.  Worry about acting on aggressive impulses.

iv.  Concern about order and symmetry.

•  Thoughts or images are not simply excessive worries about real-life problems.

•Attempts to ignore or suppress such thoughts or images with some other thought/action.

b.  Compulsions: repetitive behaviors that one feels obliged to complete. Performance of compulsive behavior, at least temporarily, decreases anxiety, thereby reinforcing behavior.

•  Common compulsions:

i.  Handwashing.

ii.  Cleaning rituals.

iii.  Requesting reassurance.

iv.  Ordering and arranging.

v.  Complex touching habits.

vi.  Checking, counting, and repetition of routine activities.

•  Behaviors are aimed at preventing or reducing distress.

c.  Obsessions or compulsions must be time consuming (take > 1 hour a day), cause marked distress, interfere with daily activities.

d.  Often seen with comorbidities.

e.  Strong familial component.

f.  Immune response to streptococcal infections.

3.  PTSD.

a.  Must have exposure to traumatic event with
both
of following:

•  Actual or threatened death/serious injury or threat to physical integrity of self/others.

•  Response involving intense fear, helplessness, horror. May be expressed as disorganized/agitated behavior in children.

b.  Traumatic event is persistently reexperienced in one or more of following ways:

•  Recurrent, intrusive, distressing thoughts of event. In young children, may include repetitive play.

•  Recurrent distressing dreams. In children, may be frightening dreams without recognizable content.

•  Acting or feeling as if trauma were reoccurring. In young children, may include trauma-specific reenactment, often through play.

•  Intense psychologic distress on exposure to internal/external cues reminiscent of traumatic event.

•  Physiologic reactivity on exposure to internal/external cues reminiscent of traumatic event.

c.  Persistent
avoidance
of stimuli, numbing of general responsiveness with 3 or more of following:

•  Efforts to avoid thoughts, feelings, or talking about trauma.

•  Efforts to avoid activities, places, people that arouse memories.

•  Inability to recall important aspect of event.

•  Diminished interest/participation in activities.

•  Feelings of detachment/estrangement.

•  Restricted range of affect.

•  Sense of foreshortened future.

d.  Persistent symptoms of
arousal
with two or more of following:

•  Difficulty falling asleep/staying asleep.

•  Irritability or outbursts of anger.

•  Difficulty concentrating.

•  Hypervigilance.

•  Exaggerated startle response.

e.  Duration of symptoms for > 1 month.

f.  Disturbance causes significant distress or impairment in functioning.

g.  Diagnosis may be acute (symptoms < 3 months), chronic (symptoms ≥ 3 months), or delayed (onset of symptoms at least 6 months after stressor).

4.  Separation anxiety.

a.  Onset of excessive anxiety on separation from home/major attachment figure
beyond what is expected
for developmental level as evidenced by 3 or more of following:

•  Recurrent excessive distress on separation from home or major attachment figure.

•  Persistent/excessive worry about losing or harm coming to major attachment figure.

•  Worry that untoward event will lead to separation (e.g., getting lost or kidnapped).

•  Reluctance or refusal to go to school.

•  Fearful or reluctant to be alone.

•  Reluctance or refusal to go to sleep without being near attachment figure or to sleep away from home.

•  Repeated nightmares with themes of separation.

•  Repeated physical complaints when separation occurs or is anticipated.

b.  Symptoms must be present for at least 4 weeks and must begin before age 18.

c.  Symptoms must cause significant distress/impairment at home, school, with friends.

E.  Physical findings.

1.  May present with symptoms of sleep disturbance, tiredness, school problems, restlessness, irritability, somatic complaints (sweating, nausea, diarrhea, shortness of breath, dizziness, headaches).

2.  For OCD, parents generally bring children in due to increase in temper tantrums, decline in school performance, food restriction, dermatitis. Children rarely request help; may be secretive about thoughts, behaviors.

F.  Diagnostic tests.

1.  None. Requires interview with child and parent/caregiver.

2.  Consider collateral contact with school personnel, especially with separation anxiety.

3.  Assess recent life stressors (family move, death, divorce, new school setting, etc.).

G.  Differential diagnosis.

1.  Attention deficit/hyperactivity disorder (ADHD).

2.  Differentiate among anxiety disorders such as PTSD, separation anxiety, generalized anxiety disorder, OCD.

3.  Consider acute stress reaction if exposed to traumatic event, symptoms present < 1 month.

H.  Treatment.