2. PCPs need teachers to complete the NICHQ Vanderbilt Assessment Scale!

3. 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 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 Screen for Child Anxiety Related Disorders (SCARED): screens for anxiety disorders Patient Health Questionnaire for Adolescents (PHQ-A): screens for depression & suicidality Patient Health Questionnaire for Adolescents (PHQ-A): screens for depression & suicidality CRAFFT: screens for substance abuse CRAFFT: screens for substance abuse

7. Condition #2 (the Hulk): ADHD with co-occuring Oppositonal Defiant Disorder +/- Conduct Disorder.

10. 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.

11. Condition #3: Autism Spectrum Disorder +/- co-occuring disorders

21. Condition #4: Anxiety, Depression, etc.

22. 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. 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. However, a proper mental health evaluation with a qualified professional is the best next step. Remember, the DSM-V is 947 pages long! Remember, the DSM-V is 947 pages long!

23. DSM-V Disorders Depressive Disorders : Disruptive Mood Dysregulation Disorder Disruptive Mood Dysregulation Disorder Major Depressive Disorder (Single vs. Recurrent episode) Major Depressive Disorder (Single vs. Recurrent episode) Persistent Depressive Disorder (Dysthymia) Persistent Depressive Disorder (Dysthymia) Premenstrual Dysphoric Disorder Premenstrual Dysphoric Disorder Substance/Medication-Induced Depressive Disorder Substance/Medication-Induced Depressive Disorder Depressive Disorder Due to Another Medical Condition Depressive Disorder Due to Another Medical Condition Other Specified Depressive Disorder Other Specified Depressive Disorder Unspecified Depressive Disorder Unspecified Depressive Disorder Bipolar and Related Disorders Bipolar I Disorder Bipolar I Disorder Bipolar II Disorder Bipolar II Disorder Cyclothymic Disorder Cyclothymic Disorder Bipolar Disorder and Related Disorder Due to Another Medical Condition Bipolar Disorder and Related Disorder Due to Another Medical Condition Other Specified Bipolar and Related Disorder Other Specified Bipolar and Related Disorder Unspecified Bipolar and Related Disorder Unspecified Bipolar and Related Disorder

24. DSM-V Disorders Anxiety Disorders: Separation Anxiety Disorders Separation Anxiety Disorders Selective Mutism Selective Mutism Specific Phobia Specific Phobia Social Anxiety Disorder (Social Phobia) Social Anxiety Disorder (Social Phobia) Panic Disorder Panic Disorder Agoraphobia Agoraphobia Generalized Anxiety Disorder Generalized Anxiety Disorder Substance/Medication-Induced Anxiety Disorder Substance/Medication-Induced Anxiety Disorder Anxiety Disorder Due to Another Medical Condition Anxiety Disorder Due to Another Medical Condition Other Specified Anxiety Disorder Other Specified Anxiety Disorder Unspecified 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.

25. Condition #5: Elimination Disorders like Chronic Constipation with Encopresis

26. 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

27. Constipation (over 95% is “Functional” or not “Organic”) Classic History Usually begins or worsens soon after the child starts school. Usually begins or worsens soon after the child starts school. Child has painful bowel movements 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 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 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 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) Can eventually develop soiling in underwear (encopresis)

28. Constipation Treatment: Education Family friendly explanation of constipation Family friendly explanation of constipation Reassure parents that this is not a willful or defiant behavior Reassure parents that this is not a willful or defiant behavior Maintain consistent, positive, supportive attitude for the child Maintain consistent, positive, supportive attitude for the child Avoid punishing the child & establish a reward system! Avoid punishing the child & establish a reward system! Ensure adequate dietary fiber intake & use fiber supplement Ensure adequate dietary fiber intake & use fiber supplement Goal = BM 2x daily for 10-15 min after breakfast & dinner Goal = BM 2x daily for 10-15 min after breakfast & dinner Take advantage of the gastrocolic reflex Take advantage of the gastrocolic reflex Sit up straight with thighs parallel to ground Sit up straight with thighs parallel to ground Valsalva maneuver to increase abdominal pressure Valsalva maneuver to increase abdominal pressure No distractions while the child is pooping! No distractions while the child is pooping!

29. Constipation/Encopresis Treatment: Meds 1. “Clean out phase” or disimpaction with oral Miralax 1-2 y: 2 tsps with 4 oz of Gatorade, repeat every hour until stools are clear. 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. 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. 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. >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 “Clean out phase” or disimpaction with oral stimulant laxative Age 3-11 y: Bisacodyl 5 mg PO at beginning and end of cleanout 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 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 ) 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 Taper or titrate dose of Miralax as needed to get runny oatmeal stools

30. Constipation: Treatment Goals 1 to 2 soft (mashed potato, runny oatmeal or soft ice cream) stools per day 1 to 2 soft (mashed potato, runny oatmeal or soft ice cream) stools per day Resolution of soiling in underwear Resolution of soiling in underwear Return of rectal sensation Return of rectal sensation Empowerment of child Empowerment of child Make defecation a positive experience Make defecation a positive experience

31. Please help swiftly identify & address DB problems in children & their families by collaborating closely with PCPs.

32. “EARLY INTERVENTIONERS ASSEMBLE!” The theme is team!

33. 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.