Disruptive, Impulse Control & Conduct Disorders for NCMHCE StudyJohn R. Williams
Quick review of the essential points— DSM5 diagnosis criteria, assessments, treatments—of these disorders to better prepare for the National Clinical Mental Health Counseling Exam. This can be used like flashcards or as a presentation.
Fostering connections: Responding to Reactive Attachment DisorderCynthia Langtiw
Presentation to Early Trauma Care, A volunteer group of parents, therapists, educators and other caregivers who have experienced the chaos and challenges associated with caring for individuals with Reactive Attachment Disorder (RAD)and Early Trauma and seek to share stories and helpful resources.
http://www.earlytraumacare.com/
Depressive Disorders: An Overview of Full Spectrum. Dr. Ashok Kumar Batham.DrAshok Batham
Medical specialists outside the area of psychiatry and those who practice family medicine generally get fragmented information about mental depression. Therefore, an endeavour has been made to provide a complete overview of various depressive disorders, such as, Major Depressive Disorder (MDD), Persistent Depressive Disorder (PDD) or Dysthymia, Disruptive Mood Dysregulation Disorder (DMDD), Premenstrual Dysphoric Disorder (PMDD), Substance/Medication Induced Depressive Disorder, Depressive Disorder Due to Another Medical Condition, and other depressive disorders. DSM-5 diagnostic criteria of each of these disorders are given along with vignettes of diagnosis and treatment of the same are presented. Hopefully, this slide share will help non-psychiatrists to understand the complete spectrum of depressive disorders.
Disruptive, Impulse Control & Conduct Disorders for NCMHCE StudyJohn R. Williams
Quick review of the essential points— DSM5 diagnosis criteria, assessments, treatments—of these disorders to better prepare for the National Clinical Mental Health Counseling Exam. This can be used like flashcards or as a presentation.
Fostering connections: Responding to Reactive Attachment DisorderCynthia Langtiw
Presentation to Early Trauma Care, A volunteer group of parents, therapists, educators and other caregivers who have experienced the chaos and challenges associated with caring for individuals with Reactive Attachment Disorder (RAD)and Early Trauma and seek to share stories and helpful resources.
http://www.earlytraumacare.com/
Depressive Disorders: An Overview of Full Spectrum. Dr. Ashok Kumar Batham.DrAshok Batham
Medical specialists outside the area of psychiatry and those who practice family medicine generally get fragmented information about mental depression. Therefore, an endeavour has been made to provide a complete overview of various depressive disorders, such as, Major Depressive Disorder (MDD), Persistent Depressive Disorder (PDD) or Dysthymia, Disruptive Mood Dysregulation Disorder (DMDD), Premenstrual Dysphoric Disorder (PMDD), Substance/Medication Induced Depressive Disorder, Depressive Disorder Due to Another Medical Condition, and other depressive disorders. DSM-5 diagnostic criteria of each of these disorders are given along with vignettes of diagnosis and treatment of the same are presented. Hopefully, this slide share will help non-psychiatrists to understand the complete spectrum of depressive disorders.
i am just trying to essay child related psychiatric problems in community. At child age there have many problems and its converted into changing behavior of child towards the community. so the child problem its create the child behavior.
Schizophrenia Spectrum & Other Psychotic Disorders for NCMHCE StudyJohn R. Williams
Quick review of the essential points— DSM5 diagnosis criteria, assessments, treatments—of these disorders to better prepare for the National Clinical Mental Health Counseling Exam. This was informed by several exam prep programs, and can be used like flashcards or as a presentation.
Introduction to Depressive Disorders in Children and AdolescentsStephen Grcevich, MD
This is the slide set to the lectures I provided to the medical staff of Child and Adolescent Behavioral Health in Canton, OH during the Fall-Winter of 2018
i am just trying to essay child related psychiatric problems in community. At child age there have many problems and its converted into changing behavior of child towards the community. so the child problem its create the child behavior.
Schizophrenia Spectrum & Other Psychotic Disorders for NCMHCE StudyJohn R. Williams
Quick review of the essential points— DSM5 diagnosis criteria, assessments, treatments—of these disorders to better prepare for the National Clinical Mental Health Counseling Exam. This was informed by several exam prep programs, and can be used like flashcards or as a presentation.
Introduction to Depressive Disorders in Children and AdolescentsStephen Grcevich, MD
This is the slide set to the lectures I provided to the medical staff of Child and Adolescent Behavioral Health in Canton, OH during the Fall-Winter of 2018
This is a presentation about Factitious Disorders such as Münchhausen Syndrome as well as the controversial Münchhausen by Proxy syndrome. This is a brief introduction to the illness's
Most hospital staff and patients try to avoid rude physicians…
Lawyers look for them.
Jurors may not understand the medicine in a malpractice case, but all have been the target of rude or rushed care. This rude behavior multiplier leads to “Jackpot Justice”.
Lawyers just love a good “service lapse”- angry words, a “TUDE”, even a late return phone call, or a cranky staff person. They revel when doctors and nurses are at odds.
In fact, patients often sue not because of genuine rude behavior, but their perception of short, curt treatment, or a feeling of incomplete disclosure. How can caregivers improve their patients’ perceptions, their expectations of care, to immunize themselves against suits?
A presentation by Jennifer Rein, MSW, LICSW, and Victoria Ochoa, LICSW, Clinical Social Workers, Boston Children’s Hospital, at JDRF New England Chapter's 2nd Annual “Living Well with T1D” Symposium on March 9, 2013.
Week 5 Focused SOAP Note and Patient Case Presentation Cosamirapdcosden
Week 5: Focused SOAP Note and Patient Case Presentation
College of Nursing-PMHNP, Walden University
NRNP 6675: PMHNP Care Across the Lifespan 2 Practicum
Introduction
Psychosis is a mental condition in which a person's ideas and perceptions are disrupted,
and the individual may have difficulty distinguishing between what is real and what is not.
A health condition, medications, or drug usage can all contribute to psychosis. Delusions,
hallucinations, incomprehensible speech, and agitation are all possible signs; the patient has
incorrect beliefs and sees or hears things that others do not see or hear. The person suffering from
the disease is usually unaware of his or her actions. Medication, psychotherapy, peer support,
family support and education, and talk therapy are all options for treatment. More or less every
mental intervention is backed by evidence accumulated during the patient's initial interview; each
patient's therapy begins with a thorough medical and mental health evaluation, the incorporation
of trust, and a discussion of past mental health history, substance misuse history, family mental
health history, and so on. In this example, the patient's evaluation was documented, and a
diagnosis was made based on the information collected from the patient during the evaluation.
When the case was being developed, a therapeutic approach was designed. The patient is a 53-
year-old Caucasian male who was scheduled for an initial screening for a psychotic disorder after
his sister recommended a visit to the psychiatrist because patient's behavior changed since the
mother passed away.
Patient Initial: S.T Age: 53 Gender: Male
Subjective Data:
CC: "I was brought here by my sister because since my mother passed away, I was living on my
own and not bothering anyone. Those people outside my window they are after me. They just
want me dead".
HPI: When patient was asked " what people?". Patient said " the government sent them to get
me because my taxes are high". Suddenly patient asked the provider if she can see the birds or
hear any loud noise. The provider responded by redirecting the patient that she does not hear any
voice or see anything. When the provider how long he is been hearing the voices or seeing
things, patient said " for weeks, weeks and weeks". Patient also said the sister tapped her phone
with the government. When asked about sleep, patient said " I have not slept well because the
voices keep me up for days. I try to watch the TV, they poison my food on TV, I locked
everything down in the fridge". Suddenly patient asked " Can I smoke?". Provider said "no you
can't smoke here". Patient admit that he smokes all day about 3 packs a day. Drinks alcohol
which his sister purchased for him to last him for weeks. Patient denies use of drugs. Admit to
history of marijuana use 3 years ago before the m ...
From the National Marfan Foundation, this presentations gives an overview of Marfan syndrome and provides the school nurse with resources to identify students in need of an evaluation, make appropriate referrals, manage the healthcare and educational needs of the student, and to educate faculty and staff about the disorder. A free copy of the presentation is available to school nurses on our website at www.marfan.org.
What are the Pitfalls of Ignoring a Patient’s Family Historykanew396
The process of collecting a patient’s family history helps engage and educate them about the possibility of a hereditary condition in the family. Going through the process of risk assessment also gives breathing room to a patient as they decide on genetic testing, which can be complicated.
This presentation mainly explains about the type of patients that are encountered in day to day practice as well as how each of them should be handled to improve the communication between a doctor and the patient.
1. Munchausen Syndrome
and Munchausen
Syndrome by ProxySyndrome by Proxy
Stephen Messner, MD, FAAP
Stephanie V. Blank Center for Safe and Healthy
Children
Children’s Healthcare of Atlanta
3. Fatal child abuse
Typically from Physical abuse
Medical neglect
NeglectNeglect
Rate increasing over past years from 1.96 to
2.03 / 100K
May represent increased reporting
4. Munch…what?
Munchausen syndrome is psychiatric
diagnosis
Fake illnesses, diseases in order to drawFake illnesses, diseases in order to draw
attention to themselves
AKA self-inflicted factitious disorder
6. Origins
Named for Baron von Münchhausen
Told tall tales after returning from war
of going to the moon, etc.of going to the moon, etc.
1720-1797
In 1950, Sir Richard Asher was first to
describe condition of self-harm
7. Munchausen Syndrome
Need to assume role of patient
Welcome invasive testing
Welcome surgical interventionsWelcome surgical interventions
8. Munchausen Syndrome by Proxy
(MSBP)
Pediatric falsification syndrome
Fabricated or induced illness
Polle’s syndromePolle’s syndrome
Meadow’s syndrome
9. Recent changes to nomenclature
APSAC recommends use of terms:
Pediatric condition falsification – describe the
abuse itselfabuse itself
Factitious disorder by proxy – describe the motive
behind the abuse
Munchausen Syndrome by Proxy when both are
present
10. MSBP
First described in 1977 by British pediatrician
Sir Roy Meadow
2 mothers
One fed child excessive amounts of salt
One put her own blood in child’s urine specimens
Intentionally producing physical and/or
psychological signs or symptoms in another
person
11. MSBP
Typically seen in children
Form of physical, sexual abuse and/or neglect
Falls under child abuse laws in terms of reportingFalls under child abuse laws in terms of reporting
Cases documented in adults
12. MSBP
Different from somatoform disorder
Signs/symptoms real to person
Not voluntary, not simulatedNot voluntary, not simulated
Different from malingering by proxy
Children coached to fake disabilities
Secondary gain
14. MSBP families
Siblings often victims
Study by Bools 1992
30% siblings poisoned or abused30% siblings poisoned or abused
Numerous sibling deaths
Sibling deaths from SIDS
Sequential MSBP reported 1998 by Arnold
Benadryl poisoning
2 siblings
16. Producing illness
Caregiver causes a condition in the child
Poisoning child
Asphyxiating childAsphyxiating child
Much more common than simulating illness
Rosenberg study showed 70% producing
illness
17. Victims
Usually less than 5 years old
Mean age 20 months
No gender predominanceNo gender predominance
Signs/symptoms disappear when removed
from offender
18. Offender
Typically white, middle to upper class,
educated
No socioeconomic group immuneNo socioeconomic group immune
Usually mother/female caregiver
Contrast to MS – offender is typically male
Usually have healthcare training
19. Common Characteristics
MSBP Offender
Bio mother
Extensive praise to medical staff
High degree of attentiveness
Calm despite severity of child’s illness
Shelters the victim
Knowledgeable about victim’s illness
Some degree of medical education
History of similar illness as the child
Welcomes painful medical tests and procedures without question
From: Holstege and Dobmeier. “Criminal Poisoning: Munchausen by Proxy”. Clin Lab Med 26 (2006) 246
20. Common Characteristics
MSBP Victims
Dependent
Display separation anxiety
Immature
Symbiotic relationship with caregiver
Views offender as ideal parentViews offender as ideal parent
Passively tolerates medical procedures
Excessive school absence
Not involved in normal social activities
Failure to thrive
Illness corresponds with presence of caregiver
Illness resolves with close surveillance
From: Holstege and Dobmeier. “Criminal Poisoning: Munchausen by Proxy”. Clin Lab Med 26 (2006) 24
21. Suspicions for MSBP
Child with multiple hospitalizations/medical visits
Medical problems unresponsive to treatment, follow
unusual course
PE/lab findings that are highly unusual, don’t fit with
history, or are impossible
Caregiver is medically knowledgeable or is
interested in medical details
Caregiver enjoys being in hospital environment
22. Suspicions for MSBP
Caregiver expresses interest in other patients’
illnesses
Typically reluctant to leave child’s side
May be unusually calm in face of child’s illness and
is supportive/encouraging of the physician
May be angry, demanding more procedures/transfer
to “better” hospital
23. Suspicions for MSBP
Symptoms not present when away from
caregiver
May be family history of sibling withMay be family history of sibling with
unexplained illness or death
Emotionally distant relationship between the
parents
24. Intentional poisonings
McClure article 1996 case series 128 children
MSBP
40 children poisoned40 children poisoned
38 different toxins
71% were prescription drugs
Most common drugs were anticonvulsants and
opiates
25. Poisonings
Very difficult to differentiate from true illness
Window for toxicology usually closed once
realization of possible poisoningrealization of possible poisoning
26. Cases of hypoglycemia
Low blood glucose
Seen in patients with insulinoma
Also seen in patients taking insulin or oralAlso seen in patients taking insulin or oral
hypoglycemic meds
Case report in Pediatrics 2005 of patient
undergoing pancreatectomy
27. Vomiting and ipecac
Most common reported toxin in MSBP
cases
Available on Amazon.com for $2.79
Can detect emetine and cephaeline inCan detect emetine and cephaeline in
the urine for several weeks
If given chronically, can cause GI
bleed, electrolyte abnormalities,
skeletal and cardiac myopathy
Cardiomyopathy deaths reported
29. Difficulties in recognition
Majority of parents have legitimate concerns
There are medical conditions with these signs
and symptomsand symptoms
Involvement of numerous
doctors/subspecialties
30. Making the diagnosis
Need to suspect MSBP
Detailed, specific testing of blood, urine for
toxinstoxins
Resolution of symptoms when separated from
caregiver
Covert video surveillance (CVS)
31. Covert Video Surveillance
Allows for 24/7 access to child’s environment
without caregiver knowledge
Not available in all hospital settingsNot available in all hospital settings
Is available at Children’s Healthcare of Atlanta
32. Making the call for CVS
Multidisciplinary team
Doctors
NursesNurses
Risk Management
Social Work
Legal
Security
33. Role of Physician
Usually the first person to raise concerns
about MSBP
Reviews medical records to look for patterns,Reviews medical records to look for patterns,
unexplained illnesses in past
Relay to team information about work-up and
results to date
34. Role of Nursing
Have more direct interaction with patient and
family
Can fill the team in on details of hospitalCan fill the team in on details of hospital
behaviors
Give insight about mom’s interaction with
hospital staff and other parents
35. Role of Risk Management
Evaluate the need for invasion of privacy
Evaluate risk of harm to child
Make recommendations to team aboutMake recommendations to team about
necessity of CVS
36. Role of Social Work
Explore social aspects of parent
Serve as resource for parent
Report to team any information gleaned fromReport to team any information gleaned from
parent about life outside of hospital
37. Role of Attorney
Work with risk management to determine
when invasion of privacy outweighs risk of
possible harm to childpossible harm to child
Create documents allowing for CVS
38. Role of Security
Monitor the CVS 24/7
Report any suspicious activity to nursing staff
Maintain accurate documentationMaintain accurate documentation
39. Team approach
“The complexities involved in MSBP case
compilation necessitates a union of forces
within the legal, medical, social/protectivewithin the legal, medical, social/protective
service, and law enforcement professions.
There is no other type of investigation that
requires an understanding and protocol
between agencies to the degree required in
MSBP investigations”
Kathryn Artingstall in “Practical aspects of muchausen by proxy and munchausen syndrome investigation”
40. Use of CVS at CHOA
Started in 1993
41 patients monitored 1993-1997
Dr Hall published results in Pediatrics in 2000Dr Hall published results in Pediatrics in 2000
41. CHOA cases
23 of the 41 cases were determined to be
MSBP
13 required CVS in making the diagnosis and13 required CVS in making the diagnosis and
supportive of the diagnosis in 5
5 confirmed case without requiring CVS
2 confirmed by labs
2 confirmed by direct observation
1 confession
42. CHOA cases
Recurrent sepsis
Mom found to be injecting urine into IV
Unexplained lethargyUnexplained lethargy
Mom putting chloral hydrate in GTube
43. Mothers’ behaviors
Remarkable for the fabrication group
Heard on phone telling lies to family members and
friends
Mom told of need for operation and her unwillingness
Mom described constant seizures when there were
none
Moms attentive to child when medical staff present
and ignore child later
44. Atlanta profiles
All perpetrators in study were the mothers
Subsequently, there has been at least 1 father
seen on CVS harming childseen on CVS harming child
Majority of moms (55%) worked in healthcare
setting
25% worked in daycare
85% either mom or dad worked in healthcare or
daycare fields
46. Atlanta methods of injury
Suffocation
Injection of body fluid
Giving oral medicationGiving oral medication
Fabrication
47. MSBP ruled out by CVS
4 cases with CVS for suspicion of MSBP
8 month old with central sleep apnea
7 year old with multiple diagnoses7 year old with multiple diagnoses
1 year old with apneic episodes observed to have
anxious and frightened mom with false alarms
3 year old with apnea diagnosed with seizures
48. CVS in UK
2 hospitals in UK
Children admitted with ALTEs
39 children39 children
33 of 39 shown to be abused using CVS
Suffocation shown in 30 cases
Poisoning and intentional fracture observed
49. As in the AJC 3/12/07
Father caught trying to suffocate son
A father was arrested Sunday at a children's hospital, charged with trying to kill his baby.
Concerned because the 3-month-old boy was having recurring breathing problems that a battery of tests failed to diagnose,
hospital officials placed a camera in the baby's room and were shocked by what they saw: The boy's father, police said, had
his hands over the infant's mouth and nose, suffocating him.
Staffers stopped the father and called police. The father, Michael Charles Callaway, is now in the Fulton County Jail,
charged with aggravated assault and cruelty to children.
Callaway's son had been at the Children's Healthcare of Atlanta at Scottish Rite since late February.
Sandy Springs police said the child was placed in a room with a hidden video camera, which caught Callaway, 28, of
Blairsville, covering his child's nose and mouth deliberately, said Lt. Steve rose.
Kevin McClelland, a hospital spokesman, said hospital officials are working with authorities but would not release any details
about the case, citing patient confidentiality and the ongoing criminal investigation.
Rose said police are trying to see whether it is a case of Munchausen Syndrome by Proxy, a mental condition where a
caregiver induces an illness in a person under their care in order to attract attention to themselves.
The boy was released from the hospital Monday because doctors found nothing wrong with him.
50. Despite proven MSBP, there’s
the discredited theory of Mothers Against
Munchausen Syndrome by Proxy Allegations
51. Per the website www.msbp.com
“The madness continues as the "experts" debate over this controversial diagnosis. Some say it is rare,
while others claim it is common. The evolution of this diagnosis continues as even the name is
debated...Factitious Disorder by Proxy, Meadow's Syndrome, Pediatric Falsification, etc. All while vying to
be the top expert in this field, some claim it is a psychiatric condition, while others state it is a medical
diagnosis, or a pattern of behavior. Yet they all involve identifying the psychological motivation of the
parent. Munchausen by Proxy is not recognized by the American Medical Association or the American
Psychiatric Association. Any physician who diagnoses this 'disorder' rather than identifying actual abuse byPsychiatric Association. Any physician who diagnoses this 'disorder' rather than identifying actual abuse by
medical evidence, should be reported to the Ethics board.
Innocent Mothers Are Profiled and removed from their medically fragile child without any evidence that
a crime has even occurred. Often, on the basis of a single phone call from a doctor, CPS will rush in and
confiscate a child without even interviewing the parents, leaving the "investigation" to the accusing
physician! Mom and dad will be instantly treated as criminals, guilty until proven innocent, and may lose
the rest of their children as well. In reality, the accusers, medical caregivers and Child Protective Service
(CPS) workers often perpetrate the real abuse.”
52. Stems from a case at Vanderbilt
Philip Patrick
Died at 11 months of age
Mother, Julie, started the webpageMother, Julie, started the webpage
She was exonerated after review of autopsy
showed he died of peritonitis
MSBP was given as initial cause of death and
parents were only allowed limited visitations
53. AAP
Recognize MSBP
States that CVS is not the gold standard for
diagnosis of MSBPdiagnosis of MSBP
Advises use of multidisciplinary team
approach to cases of suspected MSBP
54. Dr Meadows
First to describe MSBP in UK (1977)
“one sudden infant death is a tragedy, two is suspicious and
three is murder, until proved otherwise“ – Meadow’s Law
Expert testimony about cot death and MSBPExpert testimony about cot death and MSBP
Sally Clark found guilty of death of her 2 sons mainly due to
Meadows’ testimony
Court overturned some convictions in past
Does NOT discount diagnosis of MSBP
Often cited by defense to counter MSBP diagnosis
55. A diagnosis is made, now what?
First and foremost, protect the child
At CHOA, nurse alerted and removes child
from caregiverfrom caregiver
CVS reviewed and if felt to show intentional
harm, law enforcement notified
56. Psychiatric treatment
Needed for caregivers
Often needed for victims
Reports of having significant psychologicalReports of having significant psychological
difficulties later in life
Conversion symptoms
Fabrications
Poor school attendance
Poor concentration
57. Survivors of MSBP
Many suffer from PTSD
Difficulty maintaining relationships
InsecurityInsecurity
Often play victim role
Difficulty separating fantasy from reality
58. Role of the internet
Increasing availability of medical diagnoses to
lay persons
Potentially enabling offendersPotentially enabling offenders
Allows for sympathizers as well
59. Confusion and misdiagnosis
Patients with unexplained medical findings
may have real disease
Numerous tests often necessary to rule in orNumerous tests often necessary to rule in or
rule out various diagnoses
Don’t want to “jump” to diagnosis of MSBP
60. Doctor shoppers
Parents often take their children to numerous
doctors for “second opinions”
Seen in both MSBP and non-MSBP casesSeen in both MSBP and non-MSBP cases
Isn’t indicative of harm, and in most cases,
shows true concern
61. Role of community
Recognize that MSBP does occur
Awareness of child abuse in general
Collaboration of various agencies on theseCollaboration of various agencies on these
difficult cases
Maintain balance of privacy and protecting
children from harm
62. Refining the process
Analyze each case to make improvements
Expand surveillance of the rooms
Put plans in place for unique situations – suchPut plans in place for unique situations – such
as non-English speaking parents
Protocol
63. Case of MSBP in PICU
Not previously described
Often felt that MSBP couldn’t occur in closely-
monitored environment such as the ICUmonitored environment such as the ICU
3 year old seen being extubated by mother on
CVS
64. Increasing awareness
Needed by all medical providers in order to
diagnose MSBP early
Will save lives, invasive proceduresWill save lives, invasive procedures
Not limited to medical personnel
65. Summary of MSBP
Caregiver, typically mother, either inducing or
simulating illness in child
Perps seem to “enjoy” the medicalPerps seem to “enjoy” the medical
environment
Diagnosis often not in differential
Requires multidisciplinary team approach
There is a role for CVS
