Pediatric Examination and Board Review (56 page)

Aylward GP. Additional considerations. In: Aylward GP, ed.
Practitioner’s Guide to Developmental and Psychological Testing
. New York, NY: Plenum Medical; 1994:221-232.

Kelly DP, Teplin SW. Disorders of sensation: Hearing and visual impairment. In: Wolraich ML, ed.
Disorders of Development and Learning.
3rd ed. Hamilton, Ontario, Canada: BC Decker; 2003:329-344.

Roizen NJ, Deifendorf AO. Hearing loss in children. In: Roizen NJ, Deifendorf AO, eds.
The Pediatric Clinics of North America.
Vol 4 6. Philadelphia, PA: WB Saunders; 1999.

Willis LM, Willis KE. Hearing loss and deafness. In: Augustyn M, Zuckerman B, Caronna EB, eds.
Development and Behavioral Pediatrics: A Handbook for Primary Care
. Philadelphia, PA: Lippincott Williams & Wilkins; 2011:242-249.

CASE 34: A 4-MONTH-OLD WELL CHILD VISIT WITH A TEARFUL MOTHER

A 4-month-old boy presents to your office for a wellchild visit. His height and weight are in the 25% percentile, which represents a slight decline. When you tell this to his mother, she becomes tearful and states that she is doing everything she can to feed him, but he cries all the time. When questioned further, she gets discouraged easily when feeding him and does not have strong support from her husband, who works 14 hours a day. She discloses that she has not slept well at night and often cries for little or no reason. She appears disheveled and has not combed her hair, explaining that she cared more about her son looking good for the doctor than her.

SELECT THE ONE BEST ANSWER

1.
What percentage of postpartum women experience baby blues? What percentage experience postpartum depression? What percentage experience postpartum psychosis?

(A) 90%, 20%, 10%

(B) 90%, 10%, 1%

(C) 60%, 10%, 1%

(D) 60%, 5%, 0.1%

(E) 33%, 1%, 0.1%

2.
How would you further evaluate this mother for postpartum depression in your office?

(A) Structured Diagnostic and Statistical Manual of Mental Disorders, 4th Ed. (DSM-IV) interview

(B) Edinburgh scale

(C) Vanderbilt scales

(D) Brief Psychiatric Rating Scale

(E) no further evaluation needed

3.
Upon further questioning, what in this mother’s history would increase the likelihood of diagnosing maternal depression?

(A) maternal cigarette smoking during pregnancy

(B) family history of schizophrenia in an aunt

(C) learning that this was an unplanned pregnancy

(D) learning that mom breast-fed for 3 days but stopped because it was not enjoyable

(E) there is a past history of an episode of depression as a teenager

4.
What is the next best step in your treatment if you suspect postpartum depression?

(A) refer the mother to psychiatric treatment and counseling

(B) encourage the mother to voluntarily admit herself into a psychiatric hospital

(C) call Department of Children and Family Services (DCFS) to help explore the possibility of child neglect

(D) start selective serotonin reuptake inhibitor (SSRI) antidepressant treatment for the mother

(E) wait until the next visit to address your concerns

5.
Upon completion of a postpartum depression survey, what item would necessitate diagnosis and intervention?

(A) crying at times because she is upset or sad

(B) thoughts of harming self or baby but no intention

(C) difficulty sleeping

(D) feeling sad or miserable some of the time

(E) A and C

ANSWERS

1.
(D)
The incidence of baby blues is measured to be anywhere from 40% to 80%. Symptoms include abrupt changes in mood, difficulty sleeping, and loss of appetite. Symptoms start a few days after delivery and usually lessen within 10 days. Incidence of postpartum depression is 5%. Symptoms meet criteria for a depression disorder and can occur anytime in the first 6 months after birth. The incidence of postpartum psychosis is 0.1% and should be considered if delusions, hallucinations, or other symptoms of psychosis develop.

2.
(B)
The Edinburgh postnatal depression scale is a 10-question survey designed to be a screening tool that can effectively screen for postpartum depression. Positive screens (score >13) indicate depressive illness of varying severity and should be explored further by the clinician.

3.
(E)
The strongest predictor of a current depressive episode is a history of a prior episode of clinical depression.

4.
(A)
With a clinical impression of postpartum depression, a pediatrician should make the proper referral to a mental health professional. There is no evidence for child neglect.

5.
(B)
Any response indicating suicidal or homicidal ideation should be evaluated. If there are serious immediate concerns for the safety of the mother or her child, the pediatrician should ensure intervention through emergency services (eg, emergency department visit, phone hotlines).

S
UGGESTED
R
EADING

Brockington I. Postpartum psychiatric disorders.
Lancet
. 2004;363:303-310.

Gaynes BN, Gavin N, Meltzer-Brody S, et al. Perinatal depression: prevalence, screening accuracy, and screening outcomes.
Evid Rep Technol Assess (Summ).
2005;(119):1-8.

Heneghan AM, Chaudron LH, Storfer-Isser A, et al. Factors associated with identification and management of maternal depression by pediatricians.
Pediatrics
. 2007;119(3):444-454.

Spinelli MG. Postpartum psychosis: detection of risk and management.
Am J Psychiatry.
2009;166(4):405-408.

CASE 35: A 6-YEAR-OLD BOY WHO FAILED KINDERGARTEN

A 6-year-old boy is brought to your office because his mother is concerned about school. He is in kindergarten, but the school has told the family that he will have to repeat the year because he is not ready for first grade. He will not sit for “circle time” and listen to a story. He does not wait his turn and share toys with other children. When he is frustrated, he throws objects but not toward anyone in particular. He was suspended once for spitting from the top of playground equipment. The spit landed in a classmate’s hair, who told a teacher. He denied that he did it purposely and said that he didn’t see the classmate before he spit. In class, he constantly interrupts the class by making noises. The boy is unable to calm himself in your office and is constantly interrupting and playing with the medical equipment. He frequently clears his throat and has an unusually high amount of blinking. When questioned more about this, his mother says that he clears his throat more often when upset or worried and has been doing it since he was in preschool.

SELECT THE ONE BEST ANSWER

1.
Based on your findings, what is the most likely diagnosis?

(A) ADHD

(B) anxiety

(C) Tourette syndrome

(D) seizure disorder

(E) learning disability

2.
You start stimulant medication to help with attention and focus. What of the following might you expect after starting the medication?

(A) insomnia

(B) worsening of tics

(C) improvement of tics

(D) headache

(E) loss of appetite

3.
What is the ratio of boys to girls affected by the most likely diagnosis in Question 1?

(A) 1 to 1

(B) 1 to 2

(C) 2 to 1

(D) 4 to 1

(E) 1 to 4

4.
What medication would best treat his tics and ADHD?

(A) guanfacine

(B) risperidone

(C) lorazepam

(D) dexmethylphenidate

(E) sertraline

ANSWERS

1.
(C)
The presence of both motor and vocal tics for more than a year is diagnostic of Tourette syndrome. A large majority of children with Tourette also have comorbid symptoms of ADHD.