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Mick Storck, MD (206)469-6282 University of Washington Child Psychiatry: Clinical Challenges “you suffer captivity…but you will have contributed.

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Presentation on theme: "Mick Storck, MD (206)469-6282 University of Washington Child Psychiatry: Clinical Challenges “you suffer captivity…but you will have contributed."— Presentation transcript:

1 Mick Storck, MD (206) University of Washington Child Psychiatry: Clinical Challenges “you suffer captivity…but you will have contributed a word to the poem…” Inferno 1, 32 Jorge Luis Borges

2 Objectives This slide set is “over-inclusive”…this is a big topic…and has, historically, been allotted two hours in the clerkship. My goal is that these slides are semi-academic and semi-intriguing… and that you stay forever young. Mick Lecture goals: Discuss problem/risk prevalence Discuss problem/risk prevalence Discuss explanatory and intervention challenges in child mental health Discuss explanatory and intervention challenges in child mental health Review research status of interventions Review research status of interventions …Augmenting the Andreason/Black textbook chapter on Child Psychiatry …Augmenting the Andreason/Black textbook chapter on Child Psychiatry

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4 Peds Psych …OLD Diagnostic Categories (DSM-IV) Autistic Spectrum Disorders Autistic Spectrum Disorders –Autism, Asperger’s Disorder, Pervasive Developmental Disorder Learning Disorders Learning Disorders –Reading Disorder, Mathematics Disorder, Disorder of Written Expression Disruptive Behavior and Attentional Disorders Disruptive Behavior and Attentional Disorders –ADHD –Oppositional Defiant Disorder, Conduct disorder Mood and Anxiety Disorders Mood and Anxiety Disorders –Major depression, Dysthymic Disorder, Bipolar Disorder –Post Traumatic Stress Disorder, Obsessive Compulsive Disorder –Generalized Anxiety Disorder, Panic Disorder, Social Anxiety, Specific Phobias Somatoform Disorders Somatoform Disorders –Conversion Disorder, Pain Disorder, Body Dysmorphic Disorder, Somatoform Disorder Eating disorders Eating disorders –Anorexia Nervosa, Bulimia Nervosa, Eating Disorder Not Otherwise Specified Thought Disorders Thought Disorders –Schizophrenia, Schizophreniform Disorder, Psychotic Disorder Substance Use Disorders Substance Use Disorders –Abuse, Dependence, Intoxication, Withdrawal

5 Peds Psych NEW Diagnostic Categories (DSM-V) Neurodevelopmental Disorders Neurodevelopmental Disorders –Intellectual Disabilities –Autistic Spectrum Disorder –Learning disorders –Attention-Deficit/Hyperactivity Disorder (removed from “disruptive” disorders) Schizophrenia Spectrum and Other Psychotic Disorders Schizophrenia Spectrum and Other Psychotic Disorders –Schizophrenia, Brief Psychotic, Schizotypal Disorder, Psychotic Disorder due to medical conditions Bipolar and Related disorders, Depressive disorders Bipolar and Related disorders, Depressive disorders Anxiety Disorders Anxiety Disorders Generalized Anxiety, Panic Disorder, Social Anxiety, Specific Phobias Obsessive Compulsive Disorder Obsessive Compulsive Disorder Trauma- and Stressor-Related Disorders (now a separate category from anxiety disorders) Trauma- and Stressor-Related Disorders (now a separate category from anxiety disorders) Somatic Symptom and Related Disorders Somatic Symptom and Related Disorders –Illness Anxiety Disorder, Conversion Disorder Feeding and Eating Disorders Feeding and Eating Disorders –Anorexia Nervosa, Bulimia Nervosa, Avoidant/Restrictive Food Intake Disruptive, Impulse Control, and Conduct Disorders Disruptive, Impulse Control, and Conduct Disorders –Oppositional Defiant Disorder, Intermittent Explosive Disorder, Conduct disorder Substance Related and Addictive Disorders Substance Related and Addictive Disorders “Other Conditions That May Be a Focus of Clinical Attention”… “Other Conditions That May Be a Focus of Clinical Attention”… –Abuse, neglect, parent child problems, partner violence, educational, housing, discord with a lodger, personal history of …, wandering associated with a mental disorder… Other DSMV categories…that areNot so central for kids: sleep-wake, sexual dysfunctions, dissociatiive, neurocognitive, personality, paraphilic disorders

6 Symptom Clusters, Diagnoses & Treatment Probes YOUTH Thoughts & Thought Organization Attention & Impulse Regulation Acting Out & Social Relating Mood & Mood Regulation

7 Childhood differences (from adult dx)… Symptoms & Frequent Comorbidities Symptoms & Frequent Comorbidities (using pediatric depression as an example) Pediatric Depression  Irritability: often 1º symptom Temper tantrums Mood lability Low frustration tolerance  Somatic complaints  Guilt  Low self-esteem  Suicidal ideation (60%) Suicide attempts (30%)  Oppositional  Social isolation Additional Symptoms 40% - 70% with Comorbid Diagnosis  Anxiety disorders: 20% - 40%  Substance misuse: 20% - 30%  Disruptive behavior and neruodevelopmental disorder (incl. Conduct disorder /ADHD/learning disorders): 10% - 80% Natural History:  Median episode: 1 – 8mo  Recurrence: 20% - 60%  Bipolar Disorder: 20% - 40%

8 Nonspecific Symptoms (example of continua and overlap between sx…) Mania  Irritability  Increased Energy  Pressured Speech  Reckless Behavior  Grandiosity  Distractibility  Decreased Sleep ADHD  Grumpy  Hyperactive  Talking Fast  Reckless Behavior  Bragging  Distractibility  Restless Sleeper

9 Undercurrents: Historical Trauma (as an example of an ecologic variable… and the importance in medicine of grasping the generational nature of patient’s narrative) Collective and cumulative emotional wounding across generations that results from cataclysmic events targeting a community Collective and cumulative emotional wounding across generations that results from cataclysmic events targeting a community The trauma is held personally and collectively and is transmitted over generations The trauma is held personally and collectively and is transmitted over generations Distress generated from historical trauma is often unrecognized, misunderstood, ignored, marginalized, or invalidated Distress generated from historical trauma is often unrecognized, misunderstood, ignored, marginalized, or invalidated Brave Heart (1995); Yellow Horse Brave Heart (2000)

10 Child Psychiatry: Epidemiology  5 to 15 percent with clinically significant disorders  Below age 12 years: Boys outnumber girls,  Higher rates of behavioral/learning/developmental disorders  12 to 18 years: Girls outnumber boys,  Higher rates of anxiety/affective disorders

11 The Youth Risk Behavior Surveillance System (YRBS): The Youth Risk Behavior Surveillance System (YRBS): National probability sample of public and private schools National probability sample of public and private schools Total sample size = 16,410 Total sample size = 16,410 School-level response rate = 81% School-level response rate = 81% Student-level response rate = 88% Student-level response rate = 88% Overall response rate = 71% Overall response rate = 71% National survey every two years National survey every two years Some of “what kids are up to…” (look this up for great national data on youth…)

12 Priority Health-Risk Behaviors and Outcomes Monitored by YRBSS Behaviors that contribute to the leading causes of mortality and morbidity Behaviors that contribute to the leading causes of mortality and morbidity  Unintentional injuries and violence  Tobacco use  Alcohol and other drug use  Sexual behaviors  Unhealthy dietary behaviors  Inadequate physical activity Obesity Obesity Asthma Asthma

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15 Percentage of High School Students Who Watched 3 or More Hours/Day of Television,* 1999 – 2009 † * On an average school day. † Decreased 1999–2009, p < National Youth Risk Behavior Surveys, 1999–2009

16 Percentage of High School Students Who Exercised to Lose Weight or to Keep from Gaining Weight,* 1995 – 2009 † * During the 30 days before the survey. † Increased rapidly 1995–2001, increased less rapidly , p < National Youth Risk Behavior Surveys, 1995–2009

17 Percentage of High School Students Who Used an Indoor Tanning Device,* by Sex † and Race/Ethnicity, ‡ 2009 National Youth Risk Behavior Survey, 2009 * Such as a sunlamp, sunbed, or tanning booth one or more times during the 12 months before the survey. Not including a spray-on tan. † F > M ‡ W > H > B

18 Percentage of High School Students Who Used a Condom During Last Sexual Intercourse,* 1991 – 2009 † * Among students who had sexual intercourse with at least one person during the 3 months before the survey. † Increased 1991–2003, no change 2003–2009, p < National Youth Risk Behavior Surveys, 1991–2009

19 Juvenile delinquency …. participation in illegal behavior by minors (juveniles) (individuals younger than the statutory age of majority). minorsstatutoryage of majorityminorsstatutoryage of majority …Between 60-80% percent of adolescents, and pre-adolescents engage in some form of juvenile offense. [2] These can range from status offenses (such as underage smoking), to property crimes and violent crimes. adolescents [2]status offensesproperty crimesviolent crimesadolescents [2]status offensesproperty crimesviolent crimes …Better or worse than “conduct disorder”? (adult delinquency?…cutting and pasting from Wikipedia)

20 Percentage of High School Students Who Texted or ed While Driving a Car or Other Vehicle,* by Sex † and Race/Ethnicity, § 2011 National Youth Risk Behavior Survey, 2011 * On at least 1 day during the 30 days before the survey. † M > F § W > H > B

21 Percentage of High School Students Who Carried a Weapon on School Property,* 1993 – 2011 † National Youth Risk Behavior Surveys, 1993–2011 * For example, a gun, knife, or club on at least 1 day during the 30 days before the survey. † Decreased 1993–2003, no change 2003–2011, p < 0.05

22 Percentage of High School Students Who Reported Binge Drinking,* 1991 – 2009 † National Youth Risk Behavior Surveys, 1991–2009 * Had five or more drinks of alcohol in a row within a couple of hours on at least 1 day during the 30 days before the survey. † No change 1991–1997, decreased 1997–2009, p < 0.05

23 Percentage of High School Students Who Drank Alcohol for the First Time Before Age 13 Years,* 1991 – 2009 † * Other than a few sips. † No change 1991–1999, decreased 1999–2009, p < National Youth Risk Behavior Surveys, 1991–2009

24 Percentage of High School Students Who Ever Used Marijuana,* 1991 – 2009 † * Used marijuana one or more times during their life. † Increased 1991–1999, decreased 1999–2009, p < National Youth Risk Behavior Surveys, 1991–2009

25 Percentage of High School Students Who Ever Took Prescription Drugs Without a Doctor’s Prescription,* by Sex and Race/Ethnicity, † 2009 National Youth Risk Behavior Survey, * Took prescription drugs (e.g., Oxycontin, Percocet, Vicodin, Adderall, Ritalin, or Xanax) without a doctor’s prescription one or more times during their life. † W > H > B

26 Percentage of High School Students Who Used a Condom During Last Sexual Intercourse,* 1991 – 2009 † * Among students who had sexual intercourse with at least one person during the 3 months before the survey. † Increased 1991–2003, no change 2003–2009, p < National Youth Risk Behavior Surveys, 1991–2009

27 Youth Risk Behavior Survey questions about mood… Youth Risk Behavior Survey questions about mood… “The next 5 questions ask about sad feelings and attempted suicide. Sometimes people feel so depressed about the future that they may consider attempting suicide, that is, taking some action to end their own life. “ 24. During the past 12 months, did you ever feel so sad or hopeless almost every day for two weeks or more in a row that you stopped doing some usual activities? 25. During the past 12 months, did you ever seriously consider attempting suicide? 26. During the past 12 months, did you make a plan about how you would attempt suicide? 27. During the past 12 months, how many times did you actually attempt suicide? A. 0 times B. 1 time C. 2 or 3 times D. 4 or 5 times E. 6 or more times 28. If you attempted suicide during the past 12 months, did any attempt result in an injury, poisoning, or overdose that had to be treated by a doctor or nurse?

28 Percentage of High School Students Who Felt Sad or Hopeless,* 1999 – 2009 † National Youth Risk Behavior Surveys, 1999–2009 * Almost every day for 2 or more weeks in a row so that they stopped doing some usual activities during the 12 months before the survey. † No change 1999–2007, decreased , p < 0.05

29 Percentage of High School Students Who Made a Plan About How They Would Attempt Suicide,* 1991 – 2009 † * During the 12 months before the survey. † Decreased 1991–2009, p < National Youth Risk Behavior Surveys, 1991–2009

30 Percentage of High School Students Who Attempted Suicide,* 1991 – 2009 † * One or more times during the 12 months before the survey. † No change 1991–2001, decreased 1991–2009, p < National Youth Risk Behavior Surveys, 1991–2009

31 SUICIDE… 1. A leading cause (2 nd or 3 rd ) of death in adolescents: 2.12% of teen deaths are suicide 3. Suicidal ideation very common in adolescents: 20% per year 4. Suicide attempts: YRBS says 6% per year…wow! a. Attempts are much more common in females b. Suicides are much more often completed in males 5. What do you say to a teen or any patient who reports suicidal feelings? (next slide) 6. What are some major worries/ “red flags”? 7. Suicide attempts: 3 days (avg. period of contemplation for elders) 1 day (avg. period of contemplation for a young adult) Hours… (avg period of contemplation for a teen…especially males)

32 at the moment of despair/hopelessness… (appreciate the near universality of at least transient wishes to “give up”) After the “first rules of first aid” are followed : (approaching “the scene” safely, surveying the “ABCs”-attending to acute medical risks – e.g. lethality variables, imminent threats etc) Remember that providing health care is about fostering a renewed sense of hope and efficacy) - ask kids (and any of our patients) questions like…: -where did they think they would go? -did they imagine starting over? -Who did they think about? Were they among the living? An elder? A compadre? An elder? A compadre? -What kind of appeal to a “higher power” did they make? -What kind of appeal to a “higher power” did they make? -?What kind of appeal did the “higher power” make to them? -?What kind of appeal did the “higher power” make to them? -Did anyone notice? -At what point did they think they’d “turned the corner” (in either direction) and decided to try to live/die? -What tools came into view? The buddy system: Who will you turn to? Who turns to you? This list is certainly not meant to be a script or the only ways to approach this…we just want our patients to have the chance to not feel so alone or that the health care world isn’t strong and safe enough to give them a place to reflect.

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34 Suicide Rate, year-olds TotalFirearm Suffocation Poison Other From , the youth suicide rate dropped by about 29%, driven almost exclusively by a drop in firearm suicide. Suffocation (hanging) suicides increased, poisonings declined in the late ‘80s but were flat in the late 90s/early 2000s, and all other methods showed no change. Catherine Barber: Harvard Injury Control Research Center 29% decline

35 Majority based on anecdotal reports and adult studies Majority based on anecdotal reports and adult studies Minimal literature examining combined therapies and polypharmacy Minimal literature examining combined therapies and polypharmacy Limitations include small sample sizes, lack of controls, narrow diagnostic inclusion criteria and short duration of treatment Limitations include small sample sizes, lack of controls, narrow diagnostic inclusion criteria and short duration of treatment  Most prescriptions for psychiatric indications in juveniles considered off-label (non-FDA approved)  NIH promoting large, cooperative, multisite trials to address these concerns Pediatric Psychopharmacotherapy Evidence

36 It is more than just the pills “Body” Influences Mind “Mind” influences Body σ Sleep hygiene σ Activities change cortisol & testosterone levels, etc σ Fresh air and romping around σ Diet ψ Biofeedback –yoga,sports ψ Thoughts about actions ψ The phone call from grandma ψ Songs ψ Meal milieu ψ Media images ψ The meaning of the medication to ψ The youth ψ The parents ψ The teachers ψ The peers

37 FDA APPROVED- Peds psych meds Attention-deficit Hyperactivity Disorder Attention-deficit Hyperactivity Disorder –All amphetamine and methylphenidate formulations (≥6yo)  Dexedrine IR (≥3yo) –Atomoxetine –Guanfacine ER –Clonidine ER Aggression Aggression –Risperidone & Aripiprazole for aggression associated with autism Major Depression Major Depression –Fluoxetine (≥8yo) –Escitalopram (≥12yo) Obsessive-Compulsive Disorder Obsessive-Compulsive Disorder –Sertraline (≥6yo) –Fluoxetine (≥7yo) –Fluvoxamine (≥8yo) –Clomipramine (≥10yo) Bipolar Disorder Bipolar Disorder –Risperidone (≥10yo) –Aripiprazole (≥10yo) –Quetiapine (≥10yo) –Lithium (≥12yo) –Olanzapine (≥13yo) – acute treatment only Schizophrenia Schizophrenia –Risperidone (≥13yo) –Aripiprazole (≥13yo) –Quetiapine (≥13yo) –Olanzapine (≥13yo)

38 Regarding the Cary/Storck “Pediatric Psychopharm Charts”…. ( a separate attachment from the lecture handout) Dear Psychiaty Clerkship students, These slides are meant as, hopefully, an enjoyable quick reference for perusal for psychopharm agents that we use in child psychiatry… not the level of detail that you are expected to know for the clerkship. I will include some slides from these charts during my presentation then try to hypontize you so that you don’t think that you should memorize them. Please me if you have questions… Mick

39 A kid drew this a few years ago, probably could reverse the labels lots of times…

40 Epidemiology Dramatic increase in prescriptions over last 20 years Dramatic increase in prescriptions over last 20 years ? Over-medication ? Over-diagnosis ? Enhanced appreciation Since 2003, FDA has issued separate warnings regarding increased Since 2003, FDA has issued separate warnings regarding increased  Suicidal Ideation:  Antidepressants  Atomoxetine  Antiepileptics  Metabolic Disease  Atypical antipsychotics Recent data has resulted in the removal of FDA warnings: Recent data has resulted in the removal of FDA warnings:  Potential for sudden death and cardiovascular problems with stimulants  AAP no longer recommends routine pre-treatment cardiograms Washington State House Bill 1088 Washington State House Bill 1088 –DSHS required to monitor psychotropic use in youth

41 Stimulants Short Term Effectiveness of Stimulants for ADHD well documented Short Term Effectiveness of Stimulants for ADHD well documented  Over 200 published Randomized Control Trials (RCT), including studies with preschoolers and adults  Methylphenidate best studied, followed by dextroamphetamine and mixed amphetamine salts  65 – 75 % response rate, compared to 5 – 30 % placebo response  All stimulants equally effective  Except methylphenidate more effective if comorbid autism  FDA approval for ADHD  Age 6 for all, age 3 for DEX  FDA Black Box Warning for amphetamine salts due to cardiotoxicity  removed  Extended-release preparations  Transdermal methylphenidate  D-threo methylphenidate  Lisdexamfetamine –(Meth)amphetamine meanings?

42 α – Adrenergic Agents for “Autonomic Reactivity” -for kids who can’t “pull” their punches -hypervigilance -overarousal α 2 – Adrenergic Agonists: Several small RCTs show efficacy in ADHD Tx α 2 – Adrenergic Agonists: Several small RCTs show efficacy in ADHD Tx  Clonidine/Guanfacine  FDA recently approved long-acting guanfacine and clonidine for ADHD  (…why not the short-acting…which have been available for years and are much cheaper?... “marketing” not clinical issues…) α 1 – Adrenergic antagonist: primarily case report data… α 1 – Adrenergic antagonist: primarily case report data…  Prazosin  PTSD nightmares

43 Uses for Selective Serotonin Re-Uptake Inhibitors in Youth Depression Depression Dysthymia Dysthymia Bipolar Depression Bipolar Depression Generalized Anxiety Generalized Anxiety Separation Anxiety Disorder Separation Anxiety Disorder Panic Disorder Panic Disorder Obsessive Compulsive Disorder Obsessive Compulsive Disorder Post-Traumatic Stress Disorder Post-Traumatic Stress Disorder Autism Spectrum Disorders Autism Spectrum Disorders Chronic Headaches or Pain Chronic Headaches or Pain

44 SSRIs for Depression  Response rates 40-70% and Placebo rates 30-60%  Fluoxetine: First studied, Most consistent positive results  Only FDA-approved medications for pediatric depression:  Fluoxetine ≥ 8yo  Escitalopram ≥ 12yo  FDA Black Box Warning: Increased suicidal ideation  Increased risk of suicidal ideation during the first few months of treatment  4% for active medication vs 2% for placebo  No increase in suicide attempt  Debatable - ?increased suicide attempts concurrent with reduction in SSRI prescriptions  FDA monitoring recommendations:  All patients being treated with antidepressants for any indication should be monitored appropriately and observed closely for clinical worsening, suicidality, and unusual changes in behavior, especially during the initial few months of a course of drug therapy, or at times of dose changes, either increases or decreases.

45 SSRIs for OCD  4 Positive RCT’s, including two multisite trials –Fluvoxamine, Sertraline and Fluoxetine all found effective –All FDA-approved for Tx of pediatric OCD

46 Tricyclic Antidepressants Imipramine, Amitriptyline, Nortriptyline, Clomipramine, Desipramine the old guard….not used much now Depression: 13 studies, > 300 subjects: none were superior to placebo (50 – 60 % placebo response rates) Depression: 13 studies, > 300 subjects: none were superior to placebo (50 – 60 % placebo response rates) ADHD: several positive RCT’s, although not as effective as stimulants ADHD: several positive RCT’s, although not as effective as stimulants Enuresis: several positive RCT’s for Imipramine Enuresis: several positive RCT’s for Imipramine OCD: 3 positive RCT’s for Clomipramine, 1 RCT found Clomipramine helpful for repetitive behaviors in autism OCD: 3 positive RCT’s for Clomipramine, 1 RCT found Clomipramine helpful for repetitive behaviors in autism  Best Indications: Impramine for enuresis, Clomipramine for OCD.  Not FDA approved for Depression/Anxiety – but still can be an option

47 Understanding The Trials Combination of pharmacotherapy and psychotherapy most effective treatment for both moderate to severe depression and OCD –Mild symptoms typically remit within 4-6wks with psychotherapy alone High placebo response rates High placebo response rates Expect spontaneous remission when treating mild depression Expect spontaneous remission when treating mild depression “Placebo” is not equivalent to “no treatment” “Placebo” is not equivalent to “no treatment” Limited long-term data Limited long-term data Bias in pharmaceutical industry sponsored studies Bias in pharmaceutical industry sponsored studies

48 Treatment of Pediatric Anxiety Walkup, et al. N Engl J Med Dec 25; 359(26): Example of growing data on “combined” therapies….

49 Treatment for Adolescents with Depression Study TADS team. Am J Psychiatry 2009; 166:

50 Mood Stabilizers Lithium Lithium –One RCT (Geller et al., 1998) found lithium improved bipolar mood symptoms and substance abuse –Two positive, one negative RCTs for Disruptive Behavior/Aggression –Large Open Label Trial (Kafantaris et al., 2003) (n = 100) had a 63% response rate in adolescents with Bipolar I Disorder –Open trials of combination lithium plus other mood stabilizers or antipsychotics support benefit (Kafantaris et al., 2001; Findling et al., 2003, Pavuluri et al., 2004)  NICHD funded Multisite COLT Trial underway for youth with Bipolar I Disorder (ages 7 – 17) Lithium FDA approved for Bipolar (ages 12 years and older) Lithium FDA approved for Bipolar (ages 12 years and older)

51 Anticonvulsants / Mood Stablizers  FDA warnings about suicidality  Valproate – weight gain/rash/lPCO disease/liver & heme SEs  limited efficacy…maybe some benefit for borderline personality regulation  Lamotrigine  Effective In Adult Studies of Bipolar Depression  Open label study supports use in adolescents with bipolar depression (Chang et al., 2006) worry about Stevens Johnson syndrome/rash  Oxcarbazepine  Few Adult Studies Show Efficacy  Negative Trial in Youth (Wagner et al. 2006)  Carbamazepine  Adult Studies Not as Robust as for VPA  Topiramate  Negative adult trials, …..cognitive blunting  Inconclusive support for youth (Delbello et al, 2005)  Gabapentin  Large Controlled Trial in Adults was negative

52 Antipsychotics  Atypical antipsychotics provide the largest profit to pharmaceutical companies  Molindone vs. Olanzapine and Risperidone  As effective  Fewer metabolic side effects  1/10 th the cost  No longer produced!  Significant adverse effects associated with all atypical antipsychotics  Youth more susceptible to metabolic adverse effects than adults

53 Atypical Antipsychotics FDA indications for Pediatrics  Risperidone  Irritability for children and adolescents with Autism  Adolescents with Schizophrenia  Adolescents with Bipolar Disorder  Aripiprazole  Adolescents with Schizophrenia  Adolescents with Bipolar Disorder

54 Peds Psychopharm Summary  We generally treat symptom clusters that span a variety of domains of functioning and presentations of distress Domains: Cultural and Social Expectations, Social and Physical Environment, Identity, Behavioral Norms, Emotional Norms, Perceptions, Learning Systems Symptom clusters: Thought Organization, Mood Regulation, Attentional /Impulse Control Capacity, Social Relatedness  Substantial Empirical Evidence Currently Supports: Combination of psychotherapy and psychopharmacology –Stimulants for ADHD –SSRIs for Depression and OCD –Lithium for Bipolar Disorder –Antipsychotics for Psychosis Some RCT evidence for:  Antipsychotics for aggression associated with autism spectrum disorders  Alpha-agonists for ADHD symptoms, primarily as adjunctive  Very little study of polypharmacy interventions AND polypharmacy increasingly common

55 Psychotherapeutic Interventions Existing Evidence Suggests Traditional Therapies Most Often Used are Not Clearly Effective …but Existing Evidence Suggests Traditional Therapies Most Often Used are Not Clearly Effective …but –Dialectical Behavioral Therapy, Motivational Interviewing and Trama Focused – Cognitive Behavioral Thearpy are coming along… Four Meta-Analytic Studies of Psychotherapy Research Four Meta-Analytic Studies of Psychotherapy Research –> 300 studies, subjects 2 – 18 years of age –“Behavioral” Therapies Generally Superior  ?easier to measure study variables…more “reductionistic” study variables?  How would you design a study?  Effective Therapies Available, But Generally Not Used “by the book” in Clinical Settings

56 Cognitive-Behavioral Therapy Depression Depression –At least 10 Positive RCTs for Depression in Children and Adolescents  Comparison arms included wait list controls and nondirective supportive psychotherapy Anxiety Anxiety –Individual and Family CBT approaches found useful for Separation Anxiety and Generalized Anxiety Disorders –Behavioral Strategies useful for Phobias OCD OCD –some positive trials in kids, well established efficacy in adults –more robust support for “combination therapies” PTSD PTSD –Positive Trials, includes youth exposed to maltreatment –“Trauma-focused CBT” – strong momentum as Evidence-based Treatment (EBT) for children..must customize…

57 Other Behavioral Strategies Conduct/Disruptive Behavioral Disorders … Conduct/Disruptive Behavioral Disorders …  Problem-Solving Training  Anger Management  Assertiveness Training ADHD – specific interventions ADHD – specific interventions –Inconsistent findings with strategies designed to improve self control –Not much data on “neurofeedback” (fun to think about though)… –Contingency Management and Behavioral Interventions helpful  Generally not as powerful effects as stimulants.  Time Consuming, difficulty with compliance  Don’t always generalize to other settings or beyond the treatment

58 Rising stars in therapy for kids Trauma focused-Cognitive Behavioral Therapy Trauma focused-Cognitive Behavioral Therapy –Sponsored locally by the Harborview Sexual Assault Center –Customizable modules…core construct: boosting resilience through the “trauma narrative”, helping families build safety zones Motivational Interviewing: Motivational Interviewing: –Mentoring child, adolescent and family forays through their “risk grids” –Showing up, now, in a range of pediatric challenges including  Diabetes co-management, toddler sleep cycles, breast-feeding challenges Dialectical Behavioral Therapy: Dialectical Behavioral Therapy: –Individual and group components  Modified to fit for early teens, kids with developmental disabilities … –Distress tolerance strategies –Mindful practice

59 TRAUMA-FOCUSED COGNITIVE-BEHAVIORAL THERAPY Manualized Individual, Parent, and Conjoint Therapy Manualized Individual, Parent, and Conjoint Therapy Targets: Targets: –Post-traumatic Stress Symptoms  Depression, anxiety, and behaviors resultant from PTS Goals: Goals: –Eliminate symptoms PTS –Develop parenting comfort and skills confronting child’s PTS symptoms

60 TF-CBT METHOD P: Psychoeducation, Positive Parenting P: Psychoeducation, Positive Parenting R: Relaxation Techniques R: Relaxation Techniques A: Affective Expression and Modulation A: Affective Expression and Modulation C: Cognitive Coping and Processing C: Cognitive Coping and Processing T: Trauma Narrative T: Trauma Narrative I: In vivo Exposure I: In vivo Exposure C: Conjoint Child-Parent Sessions C: Conjoint Child-Parent Sessions E: Enhancing Future Safety and Development E: Enhancing Future Safety and Development

61 Parenting Training Programs Oppositional/Conduct Disorder Oppositional/Conduct Disorder Interventions Designed to enhance parenting effectiveness, decrease coercion and improve parent-child interactions, including –Behavioral Family Intervention (Patterson 1974) –Videotaped Modeling Parent Training (Webster-Stratton 1994) Parenting Interventions and Family Therapy also helpful for Parenting Interventions and Family Therapy also helpful for –Anxiety Disorders –Eating Disorders –Early childhood parent-child challenges…  Go see PCIT (Parent Child Interactive Therapy) if you can…

62 Multisystemic Therapy (MST) Aggressive case management, Comprehensive Psychiatric services and Targeted Family Interventions used to maintain youth in their homes and community systems Aggressive case management, Comprehensive Psychiatric services and Targeted Family Interventions used to maintain youth in their homes and community systems MST has better outcomes (including reduced substance abuse) and more cost-effective than MST has better outcomes (including reduced substance abuse) and more cost-effective than –Hospitalization –Incarceration However, effects may dissipate over months (Henggeler et al., 2003) However, effects may dissipate over months (Henggeler et al., 2003)

63 Psychotherapy In Children and Adolescents: Summary Best Evidence for Best Evidence for –CBT for Depression, Anxiety, PTSD –CBT/behavioral strategies for conduct problems –Parent Training for preschool challenges and conduct problems –MST for Conduct Problems Despite the availability of these Interventions Despite the availability of these Interventions –Most clinicians not systematically trained to use them –Most psychotherapy done in community settings is supportive in nature, and may not be so effective

64 DSM V (just issued …2013)  For the psychiatry clerkship, we hope you appreciate the big picture of child diagnoses, peruse the diagnostic criteria to have familiarity with how we conceptualize.  Note some changes from DSC IV to DSM V…  ADHD now a “neurodevelopmental” disorder…not primarily categorized as a “disruptive behavior” disorder  Changing the age of onset developed in DSM-IV (from 7 to 12?)  Fewer symptoms required for a diagnosis of adult ADHD  PTSD was taken from the “Anxiety” disorders category and given it’s own realm  Autism category streamlined: Did away with “Aspergers”  new “mood dysregulation” disorder (? Helps broaden the mood disorder options) The following slides, with some diagnostic criteria, are not meant to be inclusive…just a sampling of some of the diagnostic realms and angles we encounter in child psychiatry

65 ADHD Criteria: Inattention Six or more of the following for >6 mos Six or more of the following for >6 mos (Must be maladaptive and inconsistent with developmental level) (Must be maladaptive and inconsistent with developmental level) –careless with details –can’t keep on task –doesn’t seem to listen when spoken to –doesn’t follow through with instructions –difficulty organizing –reluctant to put in effort for school or homework –often loses things necessary for activities –is easily distracted –is forgetful

66 ADHD Criteria: Hyperactivity-impulsivity Six or more of the following for >6 mos Six or more of the following for >6 mos –Must be maladaptive and inconsistent with developmental ( level) Hyperactivity Hyperactivity –often fidgets with hands or feet or squirms in seat –often climbs or runs about … or feels restless –difficulty playing or engaging in leisure –often leaves seat when expected to remain in seat –often is “on the go” or acts as if “driven by a motor” –often talks excessively Impulsivity Impulsivity –often blurts out answers before questions completely asked –has difficulty awaiting turn –often interrupts or intrudes on others

67 Bipolar Disorder  Most disruptive, irritable children do not have bipolar disorder  New category of bipolar spectrum “mood dysregulation disorder” –Given that so few kids have full bipolar pictures…how will this “new” disorder fit? Prevalence of Bipolar Disorder Debated Prevalence of Bipolar Disorder Debated –Estimates range between 0.4% - 6%, depending on symptom severity –Best estimate adolescent prevalence similar to adult: 1% –0.3% - 0.5% adults with bipolar had symptom onset before 10yo  Peak incidence between 15 – 30yo Psychosis with mania, frequent mood switching, and comorbidity with ADHD are common Psychosis with mania, frequent mood switching, and comorbidity with ADHD are common Unclear how youth symptoms associated with adult course Unclear how youth symptoms associated with adult course

68 Conduct /Oppositional Defiant Disorder Oppositional Defiant Disorder: …for six months Oppositional Defiant Disorder: …for six months –Negativistic, pain in the …  Loses temper, argues  Defies  Deliberately annoys/easily annoyed  Angry, resentful, spiteful  Wonder about the family variables Conduct Disorder : 3 or more in the last 12 mos. of behaviors like Conduct Disorder : 3 or more in the last 12 mos. of behaviors like –Truancy, runaways –Aggression to people animals –Destruction of property –Deceitfulness/theft –Serious violations of rules (though it easier to “get this dx” than we might wish…) –Can occur as part of other diagnoses (see PTSD) –We always have to wonder about the “function” of the behavior….

69 Trauma- and Stressor-Related Disorders Reactive Attachment related to extreme/insufficient care…. significant impact on affiliation debate on how to constue this after age 5 Posttraumatic Stress Disorder DSMV now has appreciation of special early childhood features Re-experiencing phenomena (flashbacks, nightmares) as with adults Avoidance and trust issues… Re-enactment issues can be very different from adults… Look at play themes Conduct regulation

70 Psychosis in children and adolescents Schizophrenia is much rarer than in adults Schizophrenia is much rarer than in adults Hallucinations in pre-adolescents are often anxiety (including PTSD) phenomena Hallucinations in pre-adolescents are often anxiety (including PTSD) phenomena (until “proven” otherwise) Brief psychotic disorders…can be related to Brief psychotic disorders…can be related to  Obsessionality/anxiety  Post-traumatic stress disorder  Organic varilables Psychosis often occurs in bi-polar mania Psychosis often occurs in bi-polar mania …. and adolescent depression …. and adolescent depression Organic contributors Organic contributors  Neurologic/endocrine  Eating disorders  Autistic spectrum struggles  Severe and profound intellectual disabilities

71 Autism Spectrum Disorder  now includes a wide range of functioning…including what used to be called Aspergers Disorder…  Deficits in in social interaction and communication  Deficits in nonverbal communication skills  Failure to develop appropriate peer relationships  Lack of social understanding, interests, reciprocity  Restricted repetitive and stereotyped patterns of behavior  Preoccupation with idiosyncratic interests  Inflexible adherence to routines/rules  Stereotypic motor mannerisms  can occur with or without intellectual or language impairments  Severity:  Level 3 – requiring very substantial supports  Level 2 – requiring substantial supports  Level 3 – requiring support…

72 Jokes - by Ralph (age 12) “Ralph” met criteria for Autistic Spectrum disorder… (level 1 – high functioning) I think that one of these might be a joke…. WHY did the pig cross the road? To have some bacon and eggs. WHY did the boy throw the clock out the window? Because it woke his parents up, and now he has consequences! WHERE’S boogie world? Its all up your nose! WHAT’S black and white and red all over? A newspaper that you spilled ketchup on!

73 Anorexia and Bulimia Anorexia Nervosa Anorexia Nervosa –(the most life-endangering psychiatric diagnosis) –Restriction in energy intake –Intense fear of gaining wt –Disturbance in way body wt is experienced –10:1 female/male ratio –No longer a criterion regarding missed menstrual cycles –severity based on BMI …contemplate the role of “the web” and social media (con and pro) (con and pro) Treatment approaches: meal support, activity restriction, monitor electrolytes, EKG Bulimia Nervosa Bulimia Nervosa –Bingeing –Sense of loss of control –At least once a wk for 3 mos. –Self-evaluation is unduly influenced by body shape/weight –Be mindful of frequency of transient eating problems

74 Resilience What protects some kids? What protects some kids? –temperament (arousal patterns/mood template) –cognitive profile –birth order –specific ties inside or outside the “family” –locus of control, well played age-specific defenses –finding someone at the right time –luck at avoiding the poorly timed risk (the beer, the peer insult, the shaming moment etc) –what seems like resilience now may correlate with problems later…and vice versa

75 You’re the doctor… 1. Build alliances (with permission, check in with, or at least wonder about, home/family, peers, primary doc, school staff, coaches, chaplain, etc) 2.Your job is to help boost your patient’s adaptation and self-efficacy. 3.Ask “What is going well for you ?” and “What are you/they worried about?” 4.Help the kid look at their matrix of supports/influences. 5.Assess patient’s risk management skills, use your motivational interviewing techniques. Be the “consultant”. Get the kid to be the lead investigator. 6.Maintain alliance (availability for check ins, track attributions, follow strengths) 7.Remember your own “serenity prayer”… 8.Savor the camaraderie and access to hopes and humanity.


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