Peds 2 - lect 1 - Spring 2017 -development

1) 6 year olds can draw?
2) 7-10 year olds Erickson stage?
Click the card to flip 👆
1 / 36
Terms in this set (36)
1) 6 year olds can draw?
2) 7-10 year olds Erickson stage?
1) triangle
2) Industry vs inferiority
Tasks of Adolescence:
1) Establish?
-peak period for family conflict?
2) Peer relations in early vs later adolescence?
--
3) Stanley Hall coined phrase "storm and
stress = 3 key elements of adolescent development
--
4) Tasks of Adolescence
-in Kohlberg's theory
-greater ability to?
-Morality less __ and more...
-May question values of (2)
1) autonomy
-15-17 (Peer group primary social support 15-17)
2) Same sex peer relationship in early adolescence, Dating in later adolescence
--
3) Conflict w/parents, Mood disruption, Risky behavior
--
4) - shift from preconventional to conventional level of morality
- take others' perspectives
- concrete and rule-based, more focused on role obligations and how one is perceived by others
-parents and institutions
Phases of Adolescence: Neinstein
-Early
-Middle
-Late
------
1) If you see DEC'd muscle mass in male - consider what?
-Early = 10-13 aka Tween yrs
-Middle = 14-16
-Late = 17-21
-----
Klienfelters
Early/Pre Adolescence Years: 10-13

1) ... can lead to poor self esteem
2) ... leads to potential for early sexual intercourse
3) Psychological concepts? (2)
-Tendency to ?
-vocational goal?
4) Social Development= Beginning separation from family
-INC'd (2)
-Cont'd reliance on family for ?
-Peer group increasingly important: (2)
5) Cognitive Development...
-Decisions are based on one's own (2)
-Cannot (2)
6) Symptoms in this age range are more?
7) ... can begin at urging of older socially advanced peers
1) Early female maturation and late male maturation
2) Earlier pubertal maturation
3) Personal fable = I wont get hurt; Imaginary audience = w/pimple, everyone is watching;
-magnify the situation ... Egocentricity
-Unrealistic or idealistic
4) INC'd desire for independence & resistance to parental supervision
- structure and support
-Same sex social group =key, Idealized friendships
5) -perception and direct experiences
-plan into the future or conceive long-range implications of actions or decisions
6) vague
7) Time when injurious risk taking behavior-drinking, sex, smoking
Middle Adolescence: 14-16

1) Max level of?
2) Psychological Development: they feel/they are?
3) Cognitive development- what type of thinking increases?
4) Intense peer involvement
-Conformity with peer?
-Strive for ?
-challenges to?
5)Sexual___
- Relationships are?

Rita's tip?
1) conflict with parents
2) invincible (I can do it all attitude, risk taking/limit testing can be + or -), Impulsive
3) abstract thinking abilities
4) -values, code and dress (peer pressure + or -)
-emancipation from family: Interest/activities outside home, Employment = $ independence
-parental authority
5) experimenting (Idealistic, romantic fantasies) -Relationship = brief and self serving

Tip: contracting... parent cant deal with X so asks son,what is y so you wont do x
Late Adolescence: 17-21
(1) Psychological Development:
-goals are?
-development of?
-ability to?
(2) Cognitive development:
-firmly established?
-ability to make __ decisions? d/t awareness of?
-Ability to predict ?
(3) Social development:
-peer group?
-Friendships?
(4) Sexual Development:
-Acceptance of?
-Intimate relationship based on?
(5) Moral Development: -Recognize?
1) -realistic, can plan for future & delay gratification
-conscience
-compromise
2) - Abstract thought
- independent; personal limits/limitations
-probable outcomes, consequences
3) - peer grp values Less important
-fewer but more selective (mutual interests, values, caring, reciprocity)
4) -sexual identity
-giving & sharing, not exploration & romanticism
5) -multiple points of view, complex interrelationships, ambiguity, society values vs individual rights
Tanner stage - Female
I no hair
II (10-12) breast budding
III (11-13)
IV (12-14) areaola + Papilla form 2ndary mound
V (13.5-adult) mature
Image: Tanner stage - Female
Tanner stage **
Image: Tanner stage **
Tanner stage - Male
Image: Tanner stage - Male
Scoliosis =
A) look for? (4)
B) Test?
D) Meter?
E) Most common pattern?
=Presence of body asymmetries
A) -Shoulder/Shoulder blade height unequal (AC joint level)
- Scapular & Chest prominences (also hip)
- Unequal line from C7 (spine curved)
- Unequal gaps btwn arms & trunk

B) Adams Forward bend test = Bend forward w/both arms hanging free. Test spine at 3 levels:
-Thoracic
-Thoracolumbar
-Lumbar

C) >10 degrees of scoliosis = abnormal
Scoliometer: Angle of >7 degrees is a/w 20 degrees of scoliosis

E) right thoracic & left lumbar
AAP Table: 1) Vision Screening 2) Substance Use Assessment 3) Depression 4) Dyslipidemia 5) Hematocrit or hemoglobin 6) STI screening 7) Cervical dysplasia1) visual acuity screen recommended at 4 and 5, as well as in cooperative 3 year olds [Basically routine screening every other yr in adolescence, last required at 15] -Instrument based screening may be used to assess risk 1&2 2) CRAFFT (Car, Relax, Alone, Forget, Friend, Trouble) start at age????? 3) at ages 11 through 21 - PHQ-2, 9, A 4) btwn 9 & 11 - not well correlated to adult levels 5) risk assessment 15m, 30m 6) HIV, G&C start at 13 (AAP 16-18), NO routine: - Trich unless new/multiple partners, Hist of STI -syphilis unless MSM (annually to q3-6m) 7) at 21! (immunocompromised annual PAP tests w/onset of sex)Indications for pelvic exams prior to age 21... (10)-Persistent vaginal discharge -Dysuria or UTI symptoms in sexually active female -Dysmenorrhea unresponsive to NSAID drugs -Amenorrhea -Abnormal vaginal bleeding -Lower abdominal pain (PID...) -Contraceptive counseling for an intrauterine device or diaphragm -Perform Pap test -Suspected/reported rape or sexual abuse -PregnancyHypertension and Metabolic Syndrome (5 components) How to pick BP cuff size?Increase in Waist circumference Elevated serum triglycerides levels Low serum HDL cholesterol Impaired glucose tolerance Hypertension #s: 18+ Guidelines = M >40", F >35" CUFF BASED ON ARM CIRCUMFERENCE -Bladder length is supposed to be 80% to 100% of your arm CIRCUMFERENCE -Bladder width is supposed to be 40% or more of your arm circumference -pt rest for 5 min, seated position w/feet on floor, arm supported at heart level.Hypertension: If BP is high?(1a) BP <90th %ile, repeat in 1 y (1b) BP ≥90th %ile: Repeat BP ×2 manual; then average 3, reeval category... AVERAGED results: (2a) >90th %ile, (but <95th %ile) = preHTN: Rx = Heart Healthy diet; weight DEC?, Repeat BP in 6m (2b) ≥95th %ile, <99th %ile+5mm Hg: Repeat BP in 1-2 wk, average all BP measurements, reeval BP (2c) ≥99th %ile + 5mm Hg = Repeat BP manual × 3 at that visit!!, average all BPs, reeval BP category ON REEVAL: (3a) BP >95th %ile, <99th %ile+5mm Hg = STAGE 1 HTN, Rx = Basic work-up (urine + comp. metabolic panel) (3b) BP >99th %ile + 5mm Hg = STAGE 2 HTN, Rx =Refer to pediatric HTN expert within 1 wk OR begin BP treatment & initiate basic work-upHypertension = ? A) age to start taking BP?=Ave. sBP and/or dBP that is >/= 95th %ile for gender, age, & height on 3+ occasions A) 3 yrs, interpreted for age/gender/heightBP at 18-21y measure when? Levels of HTN Sports and hypertension - restricted? (2) -Recommend?Measure BP at all health care visits -BP ≥120/80 to 139/89 = pre-HT -BP ≥140/90 to 159/99 = stage 1 HTN -BP ≥160/100 = stage 2 HTN Restricted when: -symptomatic -uncontrolled hypertension --> DASH diet (INC'd fruit/veg & low fat dairy, DEC salt)(A) HTN and organ damage - major risks? (4) ** Look for what w/longstanding HTN (B) 1st line treatment for stage 1 HTN: (2) (why does 1 work)(A) -Heart: left ventricular hypertrophy** -Kidney** -Eyes** -Brain: encephalopathy, seizures, CVA evaluation (B1) -Child 1 diet (follows DASH guidelines) -Weight loss/Prevention of excess weight Correlation btwn obesity & HTN: -Average sBP DEC from 5-20 mm/Hg/10kg DEC (B2) Weight loss combined w/INC physical activity = INC'd antiHTN effectTB Testing... -ignore? -When use PPD, when use other? -Do not? - ... needs screening (2)-BCG administration is ignored -PPD cheaper; Can use Interferon Gamma Release Assay (IGRA) if over 5yrs -No routine screening w/low risk kids -Need screening: travel to foreign countries, many schools require PPD on entry to junior highRisk Factors for Dyslipidemia: (1) High level (5) (2) Moderate level (4) (3) High Risk conditions for Dyslipidemia (4) Moderate Risk conditions for Dyslipidemia(1a) HTN needs meds (BP≥99th%ile+5mmHg) (1b) Current cigarette smoker (1c) BMI at the ≥97th %ile (1d) Presence of high-risk conditions (1e) DM also a high-level risk fact. 2a) HTN that does not require meds 2b) BMI at the ≥95th%ile, <97th%ile 2c) HDL cholesterol <40 mg/dL 2d) moderate risk conditions 3a) T1DM + T2DM 3b) kidney (chronic, end stage, transplant) 3c) heart transplant 3d) Kawasaki w/current aneurysms 4a) Kawasaki w/regressed coronary As 4b) Chronic inflammatory disease (systemic lupus erythematosus, juvenile RA) 4c) HIV infection 4d) Nephrotic syndromeLipid Screening Recommendations: A) No screening for? B) Selective screening if? C) Universal screening?A) below 2 yrs B) 2-10yrs & 11−18 yrs IF... -1) Family history (+) for early CVD -2) Parent with known dyslipidemia -3) Child with established RF -4) Child with special risk condition C) 10 yrs, 16-18yrsLipid Distribution (mg/dL) for Children and Adolescents ACCEPTABLE // ABNORMAL TC LDL‐C TG HDLTC <170 -- >200 ** LDL‐C <110 -- >130 Non‐HDL‐C <120 -- >145 ** TG: 0−9y: <75 -- >100 10−19y: <90 -- >130 HDL >45 -- <40Dyslipidemia Algorithm1) Fasting Lipid Profile (FLP) x2, average the results (2nd test ideally in the AM) IF: LDL-C >130, TG >100 (0-10yrs) or >130 (10+yrs) 2) -Exclude 2ndary causes. -Evaluate for other RFs. -Start CHILD 2-LDL diet + lifestyle modification for 6 months... If doesnt work send to cardiology (dont write for Lipator as PNP) CHILD 2‐LDL and CHILD 2‐TG= -Saturated fat <7% of calories (hard at room temp) -Dietary cholesterol <200 mg/d -With high TGs: Eliminate sweetened beverages, reduce simple carbs, INC dietary omega 3 content + weight DEC as neededA) Tenets of shared decision making (2) --- B) Impact of Stress on Brain Development? (5) -connections -stress threshold -high stress ... ___ response -high stress damages what brain parts (2)A1) I want to review with you some of the strength you have that I've learned about as we have been talking today A2) I am concerned about X, and I hope you will be willing to discuss that with me. -Have you thought about X, what can I do to help? -------------- B) = toxic -Impairs connection of brain circuits, may= smaller brain -Develop low threshold for stress, = over-reactivity or chronic hyperarousal -High stress suppress body's immune response -Sustained high cortisol damages hippocampus (learning, memory) = cognitive deficit into adult -Verbal abuse from parents, peers interferes w/development of brain matter (grey + white)Allostatic Load -What is it, what is it due to?[long term negative impact of the stress response on the body, especially long term exposure to stress hormones like cortisol] -Wear and tear on the body and brain from large forces like socioeconomic status Example: # of children w/incarcerated parents have increased dramatically in the last 20yrs (INC's allostatic load)- Mental Health probs affect 1 in every __ children - Anorexia affects __% of adolescent girls - Anxiety disorders affect 1 in __ - ADHD affects __-__% of children - 1/3 of 6-12 year old children are diagnosed w/major depression will develop __ - 1 in __ children have a conduct disorder - Depression may be as high as 1 in __ adolescents - Suicide is the __ leading cause of death in 15-24 year olds Double depression? What is the difference btwn low mood and depression?- Mental Health probs affect 1 in every 5 children - Anorexia affects 1% of adolescent girls - Anxiety disorders affect 1 in 10 - ADHD affects 5-10% of children - 1/3 of 6-12 year old children are diagnosed w/major depression will develop bipolar - 1 in 10 children have a conduct disorder - Depression may be as high as 1 in 8 adolescents - Suicide is the third leading cause of death in 15-24 year olds Dysthymic = low mood; when depression on top of dysthymic baseline Functional impairment/affecting your life in 2+ settings.(A) Depression: -Higher rates of depression in what gender? -d/t? -Higher rate of what disorder and tendency to? -Mean length of episodes (B) Adolescent rates of depression - Higher if? (4) (C) Depression and __ is rule rather than exception?(A) -girls -after puberty d/t INC in estradiol & testosterone -anxiety disorders and tendency to rumination - 7-9 months (B) -Early onset of puberty -Experimentation with drugs and alcohol -Decreased adult supervision, incarcerated parents -Greater physiologic need for sleep w/tendency to sleep less (C) Comorbidity: -Anxiety -ADHD -Alcohol and tobacco abuse -Conduct disorder1) GLAD-PC re depression? 2) Medication management for depression? -Best class? -Best meds -KEY point? -MUST DO? 3) what else should be used for depression treatment? 4) Treat who? (3 criteria) -Refer if? (6)1) Guideline adolescent depression primary care 2) - SSRIs -Fluoxetine (prozac) & citalopram (celexa) =stat sign INC response rates vs other SSRIs. - Fluoxetine (prozac) = only 1 FDA approved for treating MDD among youth. You can initiate this (also ADHD medications) -Establish safety plan (put in chart): restricting lethal means, engaging a concerned 3rd party, developing an emergency communication mechanism should the patient deteriorate, become actively suicidal or dangerous to others 3) Psychotherapy (cognitive behavioral therapy) 4a) adolescent w/initial episode, no SI, & absence of comorbid conditions 4b) -Chronic, recurrent depression - Lack of response to initial treatment - Coexisting substance abuse or other condition - Psychosis - Bipolar symptoms - High level of family conflict1) HPV vaccine and ages? - types that = warts -types that = cancer Meningococcal: 2) Menactra - for? -ages (3) 3) Trumenba/Bexsero - for? - ages -key point1) IF 9-15 = 2 HPV shots, 6m apart IF >15-26= 3 shots (2nd 1-2m after 1st, 3rd 6m after 2nd) - (Gardasil 9 >> Cervarix) - warts = 6, 11 - cancer = 16, 18 2) N. meningitidis - Serogroups A, C, Y and W-135 - 11-12 years, w/booster dose at 16yrs (protected through period of INC'd risk, through 21). - IF 1st does is @/after 16, no booster - >21 and healthy, Not recommended to vaccinate 3) immunization to prevent invasive disease caused by Neisseria meningitidis serogroup B -ages 10-25 -NO universal recommendationTdap 2017: 1) Two products? 2) what changed? Now you can? (a) (b) 3) Contraindications to Tdap (2) 4) Precautions to Tdap (2) 5) Deferral if?1a) Boostrix (10-18 years of age) 1b) Adacel (11-64 years of age) 2) NO min interval btwn receipt of tetanus OR diphtheria-toxoid containing vaccine & Tdap when Tdap is otherwise indicated = can (a) admin single dose of Tdap to children 7-10 w/incomplete or unknown pertussis vaccine hist (b) give Tdap & Menactra (Meningococcal vaccine) together BUT need 1m interval if not co administered 3) Hist serious allergic events OR encephalopathy w/in 7 days of pertussis vaccine in past 4) -Gillian Barre syndrome 0-6w after tetanus vaccine OR Progressive neurologic disorder 5) Mod-severe acute illness OR hits of severe Arthus hypersensitivity events ?? ASK Rita 2b - does that mean same visit? cant mix shots!??Injection Site Events 1) Typical? 2) ELS? 3) Severe Injection Site Event...1) Local pain, redness, induration, fever, headache 2) Entire/extensive Limb Swelling (ELS) -4-6% following DTaP -Not a precaution, contraindication for Tdap 3) Arthus rxn = Local inflammatory rxn w/formation and deposition of immune complex and activation of complement --> Severe pain, swelling, induration, edema hemorrhage and occasional necrosisVaricella Vaccine: 1) without evidence of immunity (ages, do what?) -interval?1) 7 - 18 without evidence of immunity = 2 doses if NOT previously vaccinated or give 2nd dose if only 1 dose has been given in the past - 7-12 yrs = min interval btwn doses is 3m BUT if 2nd dose was administered at least 28 daysafter the first dose, it can be accepted as valid. For persons aged 13 years and older, the minimum interval between doses is 28 days.Hepatitis B vaccine (Hepatitis B) 1) what is the series?1a) 3-dose series to those not previously vaccinated 1b) 2-dose series (separated by at least 4 months) of adult formulation Recombivax HB is licensed for children aged 11 through 15 yearsCase 1: o 16 year old female here for well child care. Last vaccines at age 4 included 5 DTAP, 3 hepatitis, 1 HIB, 4 TOPV,1 MMR. What does she need?Case 2: 12 year old Mike transfers to your practice with the following information regarding immunizations ¤ 5 DTP (last dose age 4) ¤ 4 IPV (last dose age 4) ¤ 2 MMR (last dose age 4) ¤ Last HIB at age 18 months ¤ No history of varicella ¤ What does this child need?Case 3: 12 year old male admits to being sexually active. He comes in for routine care from another practice. His shot record shows the following— ¤ 5 DTP, 4 TOPV (last dose age 4), 1 MMR, one varicella at age 3 years ¤ What does she need and what do you do9 year old from South America ¤4 DTaP (last one at age 4 years) ¤4 IPV (last one at age 4 years) ¤1 MMR ¤No other vaccines ¤What does he need?