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MNAAP Newsletter

A Case of Elevated Liver Enzymes: Simple Virus or Suicide Attempt?

By Sarah Jane Schwarzenberg, MD, Director, Pediatric Gastroenterology, Hepatology and Nutrition, University of Minnesota Masonic Children’s Hospital and Sameer Gupta, MD, Division of Pediatric Critical Care, University of Minnesota Masonic Children’s Hospital

Case: A 15-year-old boy presented to the Emergency Department with his parents. He had been seen in an Urgent Care for vomiting and was found to have elevated liver enzymes (ALT 415, AST 475). As part of the standard panel of questions in the ED he was asked if he had thoughts of harming himself. He replied that he had such thoughts in the past, but not now. Because of this response he was questioned by a nurse and a pediatric resident with his parents out of the room. He denied self-harm, and stated he was in psychotherapy because of depression. He repeatedly denied use of acetaminophen.

His vomiting resolved after IV fluids. His liver enzymes decreased by 20 percent over 18 hours, and he was discharged with a diagnosis of viral gastroenteritis.
Two months later he attempted suicide with acetaminophen. He was hospitalized with a mild hepatopathy that quickly resolved. He admitted that the initial admission 2 months prior was the result of a similar suicide attempt with acetaminophen, during a time when he was not taking his anti-depressants.

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Screening for Mental Health Problems with the PSC-17 Tool

By Calla R. Brown, MD, Tom Scott, MD, and Iris W. Borowsky, MD, PhD

Mental health conditions are prevalent in the pediatric population, and identification and treatment at an early age can lead to improved long-term outcomes. Primary care clinics have long been promoted by the Bright Futures Guidelines for Health Supervision as the optimal site of screening for mental health conditions in the pediatric population given pediatricians’ sustained contact with children and families.

Diagnosis of mental health conditions in children through improved screening rates has been identified by the Minnesota Department of Health as a core measure in pediatrics, and there are several tools available to the general pediatrician for screening. This Minnesota goal is in line with national objectives to increase screening and treatment for mental health conditions, and Healthy People 2020 includes specific screening and treatment goals for depression in adolescents.

 

One of the most widely used and validated screening tools is the Pediatric Symptom Checklist-17 (PSC-17). While this tool is recommended in the state of Minnesota as a screening questionnaire for psychosocial problems in the pediatric population, screening rates for mental health conditions across the state as reported by the Minnesota Department of Health currently average around forty percent.

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Screening for Adverse Childhood Experiences, Psychosocial Risk, and Resilience

AndyBarnesbw150TomScottBy Andrew J. Barnes, MD, MPH, Assistant Professor, Developmental-Behavioral Pediatrics, Division of General Pediatrics and Adolescent Health, University of Minnesota and Tom Scott, MD, Clinical Professor, Developmental-Behavioral Pediatrics, Division of General Pediatrics and Adolescent Health, University of Minnesota

Although there are normative challenges during childhood – for example, separating from parents for daycare – many children experience frequent or ongoing stress that is overwhelming. Such stress, including Adverse Childhood Experiences (ACEs) and extreme poverty, can lead to modified gene expression, problems with cognitive and social-emotional development, and chronic health conditions. These negative outcomes are less likely for children with ample protective factors, whether internal (such as self-regulation) or external (such as a consistent, nurturing adult caregiver). These factors improve children’s capacity to succeed and develop well in the context of threat or challenge – i.e., resilience.

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Social Emotional Screening in Early Childhood

CatherineWrightbw150Glenace-Edwallbw150TomScottBy Catherine L. Wright, PsyD, MS, LPCC, Glenace E. Edwall, PhD, PsyD, LP, MPP, and Tom Scott, MD

Social emotional screening in primary care identifies infants, toddlers, and preschoolers in need of referral for mental health services. This screening process is currently receiving increased clinical and public health attention because of concerns about low rates of detection and treatment of behavioral and emotional problems in the United States.

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Postpartum Depression Screening in Pediatrics made Meaningful, Simple and Reimbursable

HelenKimheadshot-tessaBy Helen Kim, MD, Director of the HCMC Mother-Baby Program, and Tessa Wetjen, Minnesota Department of Human Services

The AAP has clearly stated that pediatricians must lead efforts to reduce the impact of toxic stress on children given the lifelong impact of adverse childhood experiences on physical and mental health.

Postpartum depression occurs in 10 to 35 percent of mothers (Berkule, et al., 2014) and poses a significant risk for toxic stress in children by undermining a mother’s ability to provide the nurturing interactions children need for healthy development. Children of depressed mothers or fathers are more likely to perform lower on cognitive, emotional and behavioral assessment (Berkule, et al., 2014) and have increased risk of mental health issues later in life (Ferro & Boyle, 2015).

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