MCPAP Clinical Conversations: Consults from the Field

Transcription

1 MCPAP Clinical Conversations: Consults from the Field Dr. Michele Reardon, North Shore Medical Center MCPAP Team Psychiatrist Dr. Shadi Zaghloul, Baystate Medical Center MCPAP Team Psychiatrist Dr. David Gottsegen, Pediatrician at Holyoke Pediatric Associates 1

2 Today s Speakers Michele Casoli Reardon, MD, North Shore Medical Center MCPAP Team Medical Director Shadi Zaghloul, MD, Baystate Medical Center MCPAP Team Psychiatric Consultant David N. Gottsegen, MD, Board Certified Pediatrician at Holyoke Pediatric Associates, South Hadley, MA 2

3 Consult with Dr. Reardon Presenting problem: Dr. M called MCPAP for a phone consult with Dr. Reardon about a 16-yo boy with school phobia and refusal to go to school. Disposition from phone consult was to schedule a face-to-face evaluation. Long history of attentional issues, panic and social phobia exacerbated by a concussion 1.5 years ago. Prior testing showed ADHD. Tried Strattera as a younger child but was not adherent to medication. 3

4 Consult with Dr. Reardon Increasing depression over the past several months. Developed ETOH and cannabis use but stopped cannabis recently because it made him feel paranoid ETOH continues, especially at parties to help with social anxiety Family history is significant for ADHD, Learning Disabilities, OCD, an ETOH Started on Zoloft 3 months ago for migraines following concussion but did note some improvement with social phobia while on this medication Very bright young man: VIQ 127, NVIO119, FSIQ 112 but WMI 94 and PSI 100 with deficits in attention and executive function 4

5 Key Learning points Recognize and expect comorbidity in child psychiatry Screen for the overlapping medical and neurological conditions that occur with psychiatric disorders Family history is often helpful not only in diagnosis but can also guide treatment decisions Don't assume because kids are bright and have high IQs, they can't have ADHD or LD. The two are separate. 5

6 Consult with Dr. Zaghloul Zahir, 2 year-5 month-old AA boy Referred by Dr. Gottsegen, PCP C/C: Severe temper tantrums, can last 2hours, started at 9 mos. Head banging, thrashing, rubbing face to point of bleeding Daycare aggression, hit 1 year-old brother on the head. Can t go out in public with mom due to severe tantrums. 6

7 History of Zahir Developmental delays Psychological testing by Dr. Mcquiston 24 months unable to fully participate due to variable attention and episodes of being angry during evaluation Assessed at 14 months cognitive and less than 12 months communication Dx: ASD, cognitive and communication delays and Primary mood disorder 7

8 History of Zahir Continued Medical: Severe Asthma, allergies and eczema with ICU admission for asthma. No reported head traumas (other than severe head banging) or seizures Medications: Albuterol, pulmicort and steroid cream NKDA Strong FHx of autism, bipolar disorder and suicide in maternal side of family (Mom denied mental illness herself). Father no mental illness reported. NO TRAUMA reported and no concerns re abuse voiced by EI worker 8

9 Key Learning Points Differential Dx of very young children with mood dysregulation is broad and very difficult to ascertain Consider undiagnosed physical ailments Trauma and abuse are important rule outs Anxiety continues to be the main and most common cause of irritability in children. 9

10 Key Learning Points Continued Time and longitudonal follow up clarify diagnosis. Psychopharmacological interventions are reserved for extreme cases and effectiveness and studies are lacking in this very young population. Most studies are age 5 and older Multiple classes of medications have been studied Difficult decision to start psychopharm 10

11 Additional Materials 24_p0041.pdf _2012_Article_355.pdf 11

12 Questions? 12