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PCPs need teachers to complete the
NICHQ Vanderbilt Assessment Scale!
PCPs are commonly using many other
mental health screening tools
• NICHQ Parent- & Teacher- report Vanderbilt
Assessment Scales: screens for ADHD, ODD,
conduct disorder, depression/anxiety
• Screen for Child Anxiety Related Disorders
(SCARED): screens for anxiety disorders
• Patient Health Questionnaire for Adolescents
(PHQ-A): screens for depression & suicidality
• CRAFFT: screens for substance abuse
Condition #2 (the Hulk): ADHD with
co-occuring Oppositonal Defiant Disorder
+/- Conduct Disorder.
ADHD & Co-occurring Disorders
Pediatricians can diagnose & treat children with ADHD &
co-occurring behavioral disorders from preschool age
through adolescence.
Both medications (stimulants, selective norepinephrine
reuptake inhibitors & alpha adreneric agents) &
behavioral therapy with a trained mental health provider
are effective & safe treatments for ADHD.
Effective treatments require appropriate titration &
ongoing monitoring to remain maximally effective.
Condition #3: Autism Spectrum Disorder
+/- co-occuring disorders
Condition #4: Anxiety, Depression, etc.
Know When & How To Effective
Collaborate with PCPs & Directly Refer
Children to a Mental Health Provider
• Yes, cognitive-behavioral therapy (CBT) and a
SSRI medication often improves anxiety &
depression symptoms in children & adolescents.
• However, a proper mental health evaluation with
a qualified professional is the best next step.
• Remember, the DSM-V is 947 pages long!
DSM-V Disorders
Depressive Disorders :
• Disruptive Mood Dysregulation Disorder
• Major Depressive Disorder (Single vs. Recurrent episode)
• Persistent Depressive Disorder (Dysthymia)
• Premenstrual Dysphoric Disorder
• Substance/Medication-Induced Depressive Disorder
• Depressive Disorder Due to Another Medical Condition
• Other Specified Depressive Disorder
• Unspecified Depressive Disorder
Bipolar and Related Disorders
• Bipolar I Disorder
• Bipolar II Disorder
• Cyclothymic Disorder
• Bipolar Disorder and Related Disorder Due to Another Medical
Condition
• Other Specified Bipolar and Related Disorder
• Unspecified Bipolar and Related Disorder
DSM-V Disorders
Anxiety Disorders:
• Separation Anxiety Disorders
• Selective Mutism
• Specific Phobia
• Social Anxiety Disorder (Social Phobia)
• Panic Disorder
• Agoraphobia
• Generalized Anxiety Disorder
• Substance/Medication-Induced Anxiety Disorder
• Anxiety Disorder Due to Another Medical Condition
• Other Specified Anxiety Disorder
• Unspecified Anxiety Disorder
Obsessive-Compulsive Related Disorders
Trauma- and Stressor-Related Disorders
Dissociative Disorders
Somatic Symptom and Related Disorders
Feeding and Eating Disorders
Elimination Disorders
Sleep-Wake Disorders, etc.
Condition #5: Elimination Disorders like
Chronic Constipation with Encopresis
Constipation in Children 4-18 Years
Two of the following present for at least two months:
1. Two or fewer defecations per week
2. At least one episode of fecal incontinence per week
3. History of retentive posturing or excessive volitional
stool retention
4. History of painful or hard bowel movements
5. Presence of a large fecal mass in the rectum
6. History of large-diameter stools that may obstruct
the toilet
Constipation (over 95% is
“Functional” or not “Organic”)
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Classic History
Usually begins or worsens soon after the child starts school.
Child has painful bowel movements
When urge to have a bowel movement happens, the child consciously
withholds stool by contracting their external anal sphincter and
gluteal muscles
The child might rise on their toes, rock back & forth, stiffens their
buttocks & legs, assume unusual postures, & will often hide in a
corner
Eventually, the rectum habituates to the stimulus of the enlarging
fecal mass, the urge to defecate subsides, and the retentive behavior
becomes almost second nature or subconscious
Can eventually develop soiling in underwear (encopresis)
Constipation Treatment: Education
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Family friendly explanation of constipation
Reassure parents that this is not a willful or defiant behavior
Maintain consistent, positive, supportive attitude for the child
Avoid punishing the child & establish a reward system!
Ensure adequate dietary fiber intake & use fiber supplement
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Goal = BM 2x daily for 10-15 min after breakfast & dinner
• Take advantage of the gastrocolic reflex
• Sit up straight with thighs parallel to ground
• Valsalva maneuver to increase abdominal pressure
• No distractions while the child is pooping!
Constipation/Encopresis Treatment: Meds
1. “Clean out phase” or disimpaction with oral Miralax
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1-2 y: 2 tsps with 4 oz of Gatorade, repeat every hour until stools are clear.
3-5 y: 4 capfuls in 24 oz of Gatorade, given 4 oz every 30 – 60 min.
6-11 y: 6 capfuls in 32 oz of Gatorade, given 4 oz every 30-60 min.
>12 y: 8 capfuls in 32 oz of Gatorade, given 4 oz every 30-60 min.
“Clean out phase” or disimpaction with oral stimulant laxative
• Age 3-11 y: Bisacodyl 5 mg PO at beginning and end of cleanout
• Age 12 and up: Bisacodyl 10 mg PO at beginning & end of cleanout
2. “Maintenance phase” with oral Miralax:
• 0.4 to 0.8 grams/kg per day in 2 to 8 oz of a Gatorade (max of 17 g daily is a
good starting dose )
• Taper or titrate dose of Miralax as needed to get runny oatmeal stools
Constipation: Treatment Goals
• 1 to 2 soft (mashed potato, runny
oatmeal or soft ice cream) stools per day
• Resolution of soiling in underwear
• Return of rectal sensation
• Empowerment of child
• Make defecation a positive experience
Please help swiftly identify & address DB
problems in children & their families by
collaborating closely with PCPs.
“EARLY INTERVENTIONERS ASSEMBLE!”
The theme is team!
This book provides systematic, big-picture guidance and specific
information about how to develop or strengthen your own
community’s early detection/Child Find system.