Pediatric Primary Care (136 page)

•  Improve attitudes related to eating disorder.

•  Encourage healthy, not excessive exercise.

•  Resolution of co-occurring disorders such as depression, anxiety.

c.  Treatment approaches may include individual, group/family therapy.

d.  Cognitive behavioral therapy: useful to address cognitive distortions related to body image and to develop adaptive coping skills.

e.  Antidepressant medications, especially SSRIs, have been found to be effective.

I.  Follow up.

1.  May need weekly visits to monitor weight, lab work.

2.  To achieve long-term remission and rehabilitation, treatment must include ongoing behavioral therapy, continued assessment of weight and physical health status.

3.  Ongoing assessment of anxiety/depressive symptoms.

4.  Collaboration between family and mental health provider to assess effectiveness of treatment approaches.

5.  Pharmacologic support has found conflicting evidence as benefit.

J.  Complications.

1.  Anorexia nervosa.

a.  Starvation, fluid and electrolyte imbalances, dehydration.

b.  Cardiac complications.

c.  Renal failure.

d.  Potential for suicide.

e.  Development of anxiety/depression.

f.  Potential for family stress and conflict.

2.  Bulimia nervosa.

a.  Dental caries, loss of dental enamel.

b.  Potential for development of depression, substance abuse.

c.  Gastric rupture from acute gastric dilatation secondary to vomiting.

d.  Esophagitis and ulceration of esophagus.

e.  Potential for cardiac arrhythmias.

K.  Education.

1.  Educate family on potential complications of disorder, as well as how to best support adolescent in treatment.

2.  Adolescent and family may benefit from nutritional counseling.

III.  MOOD DISORDERS

A.  Etiology.

1.  Close family member with depression or bipolar disorder may be single largest contributor to likelihood of disorder in child.

B.  Occurrence.

1.  For depression, prevalence is 2% in children, 6% in adolescents, with lifetime prevalence in adolescents estimated to be 20%.

2.  1% of adolescents 14-18 years of age meet criteria for bipolar disorder. Recent reports indicate a 40-fold increase in the diagnosis of bipolar disorder in children and teens.

C.  Clinical manifestations.

1.  Major depression.

a.  Characterized by five or more of the following symptoms present daily for at least 2 weeks:

•  Persistent sadness or irritable mood.

•  Loss of interest in activities once enjoyed.

•  Significant change in appetite or body weight.

•  Difficulty sleeping or oversleeping.

•  Psychomotor agitation or slowing.

•  Loss of energy.

•  Feelings of worthlessness or inappropriate guilt.

•  Difficulty concentrating.

•  Recurrent thoughts of death or suicide.

b.  Other signs associated with depression include:

•  Frequent, vague, nonspecific physical complaints such as stomachaches, headaches, muscle aches, tiredness.

•  Frequent absences from school or poor school performance.

•  Talk of or efforts to run away from home.

•  Outbursts of shouting, complaining, unexplained irritability or crying.

•  Being bored or lack of interest in playing with friends.

•  Alcohol or substance abuse.

•  Social isolation, poor communication, difficulty with relationships.

•  Fear of death.

•  Extreme sensitivity to rejection/failure.

•  Increased irritability, anger, hostility.

•  Reckless behavior.

2.  Bipolar disorder.

a.  Bipolar I: experiences alternating episodes of intense mania and depression.

b.  Bipolar II: experiences episodes of hypomania (markedly elevated or irritable mood with increased physical and mental energy) between recurrent periods of depression.

c.  Bipolar not specified (NOS): being used more to describe bipolar spectrum symptoms. Next edition of
Diagnostics and Statistical Manual of Mental Disorders
to include Temper Dysregulation Disorder that will better capture developmental aspect of symptoms.

d.  
Manic symptoms include:

•  Severe or rapid changes in mood: extremely irritable or overly silly, elated mood.

•  Overly inflated self-esteem, grandiosity.

•  Exaggerated beliefs about personal talents/abilities.

•  Increased energy, decreased need for sleep; able to go with very little/no sleep for days without tiring.

•  Talks too much, too fast, changes subjects too quickly.

•  Distractibility, hyperactivity: attention shifts from one thing to another quickly.

•  Increased sexual thoughts, feelings, behaviors, or use of explicit sexual language.

•  Increased goal-directed activity or physical agitation.

•  Excessive involvement in risky, daredevil behaviors/activities.

e.  
Depressive symptoms include:

•  Pervasive/overwhelming sadness, crying spells.

•  Sleeping too much or inability to sleep.

•  Agitation, irritability.

•  Withdrawal from activities formerly enjoyed.

•  Drop in grades, inability to concentrate.

•  Thoughts of death and suicide.