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Child Psychiatry: Clinical Challenges

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Presentation on theme: "Child Psychiatry: Clinical Challenges"— Presentation transcript:

1 Child Psychiatry: Clinical Challenges
Mick Storck, MD (206) University of Washington “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 explanatory and intervention challenges in child mental health Review research status of interventions …Augmenting the Andreason/Black textbook chapter on Child Psychiatry

3

4 Peds Psych …OLD Diagnostic Categories (DSM-IV)
Autistic Spectrum Disorders Autism, Asperger’s Disorder, Pervasive Developmental Disorder Learning Disorders Reading Disorder, Mathematics Disorder, Disorder of Written Expression Disruptive Behavior and Attentional Disorders ADHD Oppositional Defiant Disorder, Conduct disorder 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 Conversion Disorder, Pain Disorder, Body Dysmorphic Disorder, Somatoform Disorder Eating disorders Anorexia Nervosa, Bulimia Nervosa, Eating Disorder Not Otherwise Specified Thought Disorders Schizophrenia, Schizophreniform Disorder, Psychotic Disorder Substance Use Disorders Abuse, Dependence, Intoxication, Withdrawal Plesae just look at this as the overall “canvas” of DSM’s orientation to childhood diagnoses…and see, with the next slide that there is some shifting in how we lump and split….

5 Peds Psych NEW Diagnostic Categories (DSM-V)
Neurodevelopmental Disorders Intellectual Disabilities Autistic Spectrum Disorder Learning disorders Attention-Deficit/Hyperactivity Disorder (removed from “disruptive” disorders) Schizophrenia Spectrum and Other Psychotic Disorders Schizophrenia, Brief Psychotic, Schizotypal Disorder, Psychotic Disorder due to medical conditions Bipolar and Related disorders, Depressive disorders Anxiety Disorders Generalized Anxiety, Panic Disorder, Social Anxiety, Specific Phobias Obsessive Compulsive Disorder Trauma- and Stressor-Related Disorders (now a separate category from anxiety disorders) Somatic Symptom and Related Disorders Illness Anxiety Disorder, Conversion Disorder Feeding and Eating Disorders Anorexia Nervosa, Bulimia Nervosa, Avoidant/Restrictive Food Intake Disruptive, Impulse Control, and Conduct Disorders Oppositional Defiant Disorder, Intermittent Explosive Disorder, Conduct disorder Substance Related and Addictive Disorders “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 (using pediatric depression as an example) Pediatric Depression Additional Symptoms Irritability: often 1º symptom 40% - 70% with Comorbid Diagnosis Temper tantrums Mood lability Anxiety disorders: 20% - 40% Low frustration tolerance Substance misuse: 20% - 30% Disruptive behavior and neruodevelopmental disorder (incl. Conduct disorder /ADHD/learning disorders): 10% - 80% Somatic complaints Guilt Low self-esteem Suicidal ideation (60%) Suicide attempts (30%) Natural History: Oppositional Median episode: 1 – 8mo Social isolation Recurrence: 20% - 60% Bipolar Disorder: 20% - 40% Kids depressive profiles are different from adults…

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 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 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):
National probability sample of public and private schools Total sample size = 16,410 School-level response rate = 81% Student-level response rate = 88% Overall response rate = 71% National survey every two years Some of “what kids are up to…” (look this up for great national data on youth…) The 2009 National YRBS survey was administered to a national probability sample of public and private schools. The sample size is 16,410 students. The school-level response rate is 81% and the student-level response rate is 88%. The school response rate multiplied by the student response rate produces an overall response rate of 71%.

12 Priority Health-Risk Behaviors and Outcomes Monitored by YRBSS
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 Asthma The YRBSS monitors priority health-risk behaviors that contribute to the leading causes of morbidity and mortality among youth and adults: unintentional injuries and violence, tobacco use, alcohol and other drug use, sexual behaviors, unhealthy dietary behaviors and, inadequate physical activity. The YRBSS also monitors two health outcomes: obesity and asthma.

13 This pie graph represents the leading causes of death among persons aged years in the United States in In that year, motor vehicle crashes accounted for 30% of deaths, homicide for 16%, suicide for 12% of deaths, other unintentional injuries for 16%, and 26% of deaths were the result of other causes.

14 This pie graph represents the leading causes of death among persons aged 25 years and older in the United States in In that year, 35% of deaths were the result of cardiovascular disease, 24% were the result of cancer, and 41% of deaths were due to other causes.

15 Percentage of High School Students Who Watched 3 or More Hours/Day of Television,* 1999 – 2009†
I’ve included some of these slides for a bit of whimsy and “ethnography” of youth…it is interesting to me to contemplate the role of social media and video games on the habits, strengths and challenges for our youth… and how rapidly they can shift in a decade or so… Mick This slide shows the percentage of high school students who watched television 3 or more hours per day on an average school day (YRBS survey years 1999–2009). Across YRBS survey years 1999–2009, a significant linear decrease occurred in the percentage of students who watched 3 or more hours per day of television (42.8%–32.8%). The percentage of high school students who watched 3 or more hours per day of television was 42.8% in 1999, 38.3% in 2001, 38.2% in 2003, 37.2% in 2005, 35.4% in 2007, and 32.8% in 2009. * On an average school day. † Decreased 1999–2009, p < 0.05. 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† This slide shows the percentage of high school students who exercised to lose weight or to keep from gaining weight during the 30 days before the survey (YRBS survey years 1995–2009). The percentage of students who exercised to lose weight or to keep from gaining weight increased rapidly across YRBS survey years (51.0%-59.9%) and then increased less rapidly across YRBS survey years (59.9%-61.5%). The percentage of high school students who exercised to lose weight or to keep from gaining weight was 51.0% in 1995, 51.5% in 1997, 58.4% in 1999, 59.9% in 2001, 57.1% in 2003, 60.0% in 2005, 60.9% in 2007, and 61.5% in 2009. * During the 30 days before the survey. † Increased rapidly 1995–2001, increased less rapidly , p < 0.05. National Youth Risk Behavior Surveys, 1995–2009

17 Percentage of High School Students Who Used an Indoor Tanning Device,
Percentage of High School Students Who Used an Indoor Tanning Device,* by Sex† and Race/Ethnicity,‡ 2009 Nationwide in 2009, 15.6% of high school students had used an indoor tanning device 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). The prevalence of having used an indoor tanning device was higher among female (25.4%) than male (6.7%) students. The prevalence of having used an indoor tanning device was higher among white (21.1%) than Hispanic (8.2%) students and higher among Hispanic than black (4.5%) students. * 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 National Youth Risk Behavior Survey, 2009

18 Percentage of High School Students Who Used a Condom During Last Sexual Intercourse,* 1991 – 2009†
This slide shows, among students who had had sexual intercourse with at least one person during the 3 months before the survey (i.e., currently sexually active), the percentage of high school students who reported that either they or their partner had used a condom during last sexual intercourse (YRBS survey years ). The percentage of sexually active students who used a condom during last sexual intercourse increased across YRBS survey years 1991–2003 (46.2%–63.0%) and then did not change significantly across YRBS survey years 2003–2009 (63.0%–61.1%). The percentage of high school students who used a condom during last sexual intercourse was 46.2% in 1991, 52.8% in 1993, 54.4% in 1995, 56.8% in 1997, 58.0% in 1999, 57.9% in 2001, 63.0% in 2003, 62.8% in 2005, 61.5% in 2007, and 61.1% in 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 < 0.05. 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). …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. …Better or worse than “conduct disorder”? (adult delinquency?…cutting and pasting from Wikipedia) This slide is meant to show the breadth and frequency of some degree of ‘rule violation’

20 Percentage of High School Students Who Texted or ed While Driving a Car or Other Vehicle,* by Sex† and Race/Ethnicity,§ 2011 In 2011, during the 30 days before the survey, 32.8% of high school students nationwide had texted or ed while driving a car or other vehicle on at least one day during the 30 days before the survey. The prevalence of having texted or ed while driving was higher among male (34.9%) than female (30.4%) students. The prevalence of having texted or ed while driving was higher among white (36.2%) students than among Hispanic (30.9%) students, and higher among Hispanic students than among black (24.1%) students. * On at least 1 day during the 30 days before the survey. † M > F § W > H > B National Youth Risk Behavior Survey, 2011

21 Percentage of High School Students Who Carried a Weapon on School Property,* 1993 – 2011†
This slide shows the percentage of high school students who carried a weapon (e.g., a gun, knife, or club) on school property on at least 1 day during the 30 days before the survey (YRBS survey years 1993–2011). The percentage of students who carried a weapon on school property decreased across YRBS survey years 1993–2003 (11.8%–6.1%) and then did not change significantly across YRBS survey years 2003–2011 (6.1%–5.4%). The percentage of high school students who carried a weapon on school property was 11.8% in 1993, 9.8% in 1995, 8.5% in 1997, 6.9% in 1999, 6.4% in 2001, 6.1% in 2003, 6.5% in 2005, 5.9% in 2007, 5.6% in 2009, and 5.4% in 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 National Youth Risk Behavior Surveys, 1993–2011

22 Percentage of High School Students Who Reported Binge Drinking,
This slide shows the percentage of high school students who had five or more drinks of alcohol in a row (i.e., within a couple of hours) on at least 1 day during the 30 days before the survey (i.e., binge drinking) (YRBS survey years 1991–2009). The percentage of students who reported binge drinking did not change significantly across YRBS survey years 1991–1997 (31.3%–33.4%) and then decreased across YRBS survey years 1997–2009 (33.4%–24.2%). The percentage of high school students who reported binge drinking was 31.3% in 1991, 30.0% in 1993, 32.6% in 1995, 33.4% in 1997, 31.5% in 1999, 29.9% in 2001, 28.3% in 2003, 25.5% in 2005, 26.0% in 2007, and 24.2% in 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 National Youth Risk Behavior Surveys, 1991–2009

23 Percentage of High School Students Who Drank Alcohol for the First Time Before Age 13 Years,* 1991 – 2009† This slide shows the percentage of high school students who drank alcohol (other than a few sips) for the first time before age 13 years (YRBS survey years 1991–2009). The percentage of students who drank alcohol for the first time before age 13 years did not change significantly across YRBS survey years 1991–1999 (32.7%–32.2%) and then decreased across YRBS survey years 1999–2009 (32.2%–21.1%). The percentage of high school students who drank alcohol for the first time before age 13 years was 32.7% in 1991, 32.9% in 1993, 32.4% in 1995, 31.1% in 1997, 32.2% in 1999, 29.1% in 2001, 27.8% in 2003, 25.6% in 2005, 23.8% in 2007, and 21.1% in 2009. * Other than a few sips. † No change 1991–1999, decreased 1999–2009, p < 0.05. National Youth Risk Behavior Surveys, 1991–2009

24 Percentage of High School Students Who Ever Used Marijuana,
This slide shows the percentage of high school students who used marijuana one or more times during their life (i.e., ever used marijuana) (YRBS survey years 1991–2009). The percentage of students who ever used marijuana increased across YRBS survey years 1991–1999 (31.3%–47.2%) and then decreased across YRBS survey years 1999–2009 (47.2%–36.8%). The percentage of high school students who ever used marijuana was 31.3% in 1991, 32.8% in 1993, 42.4% in 1995, 47.1% in 1997, 47.2% in 1999, 42.4% in 2001, 40.2% in 2003, 38.4% in 2005, 38.1% in 2007, and 36.8% in 2009. * Used marijuana one or more times during their life. † Increased 1991–1999, decreased 1999–2009, p < 0.05. 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 Nationwide in 2009, 20.2% of high school students had taken prescription drugs (e.g., Oxycontin, Percocet, Vicodin, Adderall, Ritalin, or Xanax) without a doctor’s prescription one or more times during their life (i.e., ever took prescription drugs without a doctor’s prescription). The prevalence of having ever taken prescription drugs without a doctor’s prescription was 19.8% among female students and 20.4% among male students. The prevalence of having ever taken prescription drugs without a doctor’s prescription was higher among white (23.0%) than Hispanic (17.2%) students and higher among Hispanic than black (11.8%) students. * 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 National Youth Risk Behavior Survey, 2009

26 Percentage of High School Students Who Used a Condom During Last Sexual Intercourse,* 1991 – 2009†
This slide shows, among students who had had sexual intercourse with at least one person during the 3 months before the survey (i.e., currently sexually active), the percentage of high school students who reported that either they or their partner had used a condom during last sexual intercourse (YRBS survey years ). The percentage of sexually active students who used a condom during last sexual intercourse increased across YRBS survey years 1991–2003 (46.2%–63.0%) and then did not change significantly across YRBS survey years 2003–2009 (63.0%–61.1%). The percentage of high school students who used a condom during last sexual intercourse was 46.2% in 1991, 52.8% in 1993, 54.4% in 1995, 56.8% in 1997, 58.0% in 1999, 57.9% in 2001, 63.0% in 2003, 62.8% in 2005, 61.5% in 2007, and 61.1% in 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 < 0.05. National Youth Risk Behavior Surveys, 1991–2009

27 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,
This slide shows the percentage of high school students who felt sad or hopeless 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 (YRBS survey years 1999–2009). The percentage of students who felt sad or hopeless did not change significantly across YRBS survey years 1999–2007 (28.3%–28.5%) and then decreased across YRBS survey years 2007–2009 (28.5%–26.1%). The percentage of high school students who felt sad or hopeless was 28.3% in 1999, 28.3% in 2001, 28.6% in 2003, 28.5% in 2005, 28.5% in 2007, and 26.1% in 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 National Youth Risk Behavior Surveys, 1999–2009

29 Percentage of High School Students Who Made a Plan About How They Would Attempt Suicide,* 1991 – 2009† This slide shows the percentage of high school students who made a plan about how they would attempt suicide during the 12 months before the survey (YRBS survey years 1991–2009). Across YRBS survey years 1991–2009, a significant linear decrease occurred in the percentage of students who made a suicide plan (18.6%–10.9%). The percentage of high school students who made a plan about how they would attempt suicide was 18.6% in 1991, 19.0% in 1993, 17.7% in 1995, 15.7% in 1997, 14.5% in 1999, 14.8% in 2001, 16.5% in 2003, 13.0% in 2005, 11.3% in 2007, and 10.9% in 2009. * During the 12 months before the survey. † Decreased 1991–2009, p < 0.05. National Youth Risk Behavior Surveys, 1991–2009

30 Percentage of High School Students Who Attempted Suicide,* 1991 – 2009†
This slide shows the percentage of high school students who attempted suicide one or more times during the 12 months before the survey (YRBS survey years 1991–2009). The percentage of students who attempted suicide did not change significantly across YRBS survey years 1991–2001 (7.3%–8.8%) and then decreased across YRBS survey years 2001–2009 (8.8%–6.3%). The percentage of high school students who attempted suicide was 7.3% in 1991, 8.6% in 1993, 8.7% in 1995, 7.7% in 1997, 8.3% in 1999, 8.8% in 2001, 8.5% in 2003, 8.4% in 2005, 6.9% in 2007, and 6.3% in 2009. * One or more times during the 12 months before the survey. † No change 1991–2001, decreased 1991–2009, p < 0.05. National Youth Risk Behavior Surveys, 1991–2009

31 SUICIDE… 1. A leading cause (2nd or 3rd) of death in adolescents:
12% of teen deaths are suicide 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? -What kind of appeal to a “higher power” did they make? -?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.

33

34 Suicide Rate, 15-24 year-olds
29% decline Total Firearm Suffocation Poison Other This slide is included to help us contemplate risk variables and how we might approach “health promotion and risk management” with our patients and their families…This slide, in my mind, helps us appreciate prevention strategies…In the 1970’s the British suicide rate fell dramatically after tracer odors were put in household heating gas… 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

35 Pediatric Psychopharmacotherapy Evidence
Majority based on anecdotal reports and adult studies Minimal literature examining combined therapies and polypharmacy 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

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

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

38 Dear Psychiaty Clerkship students,
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
Recent data has resulted in the removal of FDA warnings: ? Over-medication Potential for sudden death and cardiovascular problems with stimulants ? Over-diagnosis ? Enhanced appreciation AAP no longer recommends routine pre-treatment cardiograms Since 2003, FDA has issued separate warnings regarding increased Washington State House Bill 1088 DSHS required to monitor psychotropic use in youth Suicidal Ideation: Antidepressants Atomoxetine Antiepileptics Metabolic Disease Atypical antipsychotics

41 Stimulants 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 α2 – 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…) α1 – Adrenergic antagonist: primarily case report data… Prazosin PTSD nightmares

43 Uses for Selective Serotonin Re-Uptake Inhibitors in Youth
Depression Dysthymia Bipolar Depression Generalized Anxiety Separation Anxiety Disorder Panic Disorder Obsessive Compulsive Disorder Post-Traumatic Stress Disorder Autism Spectrum Disorders 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. FDA Public Health Advisory (10/04): Risk for suicidality examined for 9 drugs in 24 RCT short-term trials (up to 4 months of treatment) (total n = 4400 children and adolescents)

45 4 Positive RCT’s, including two multisite trials
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) ADHD: several positive RCT’s, although not as effective as stimulants Enuresis: several positive RCT’s for Imipramine 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 Expect spontaneous remission when treating mild depression “Placebo” is not equivalent to “no treatment” Limited long-term data Bias in pharmaceutical industry sponsored studies Response: No symptoms or a significant reduction in depressive symptoms for at least 2 weeks • Remission: A period of at least 2 weeks and <2 months with no or few depressive symptoms • Recovery: Absence of significant symptoms of depression (e.g., no more than 1Y2 symptoms) for Q2 months • Relapse: A DSM episode of depression during the period of remission • Recurrence: The emergence of symptoms of depression during the period of recovery (a new episode

48 Treatment of Pediatric Anxiety
Walkup, et al. N Engl J Med Dec 25; 359(26): Example of growing data on “combined” therapies…. Figure 2. Scores on the Pediatric Anxiety Rating Scale during the 12-Week Study. Scores on the Pediatric Anxiety Rating Scale range from 0 to 30, with scores higher than 13 consistent with moderate levels of anxiety and a diagnosis of an anxiety disorder. The expected mean score is the mean of the sampling distribution of the mean. The I bars represent standard errors.

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

50 Mood Stabilizers 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)

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 1/10th 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

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

55 Psychotherapeutic Interventions
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 > 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 At least 10 Positive RCTs for Depression in Children and Adolescents Comparison arms included wait list controls and nondirective supportive psychotherapy Anxiety Individual and Family CBT approaches found useful for Separation Anxiety and Generalized Anxiety Disorders Behavioral Strategies useful for Phobias OCD some positive trials in kids, well established efficacy in adults more robust support for “combination therapies” 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 … Problem-Solving Training Anger Management Assertiveness Training 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 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: 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: 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 Targets: Post-traumatic Stress Symptoms Depression, anxiety, and behaviors resultant from PTS Goals: Eliminate symptoms PTS Develop parenting comfort and skills confronting child’s PTS symptoms

60 TF-CBT METHOD P: Psychoeducation, Positive Parenting
R: Relaxation Techniques A: Affective Expression and Modulation C: Cognitive Coping and Processing T: Trauma Narrative I: In vivo Exposure C: Conjoint Child-Parent Sessions E: Enhancing Future Safety and Development Permanent, pervasive, too personalized Accurate and Helpful? Regret and Responsibility In Vivo Exposure when appropriate to reduce traumatic reminders

61 Parenting Training Programs
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 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 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)

63 Psychotherapy In Children and Adolescents: Summary
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 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 (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 Must be maladaptive and inconsistent with developmental ( level) 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 often blurts out answers before questions completely asked has difficulty awaiting turn often interrupts or intrudes on others

67 Bipolar Disorder Prevalence of Bipolar Disorder Debated
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 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 Unclear how youth symptoms associated with adult course

68 Conduct /Oppositional Defiant Disorder
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 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 Hallucinations in pre-adolescents are often anxiety (including PTSD) phenomena (until “proven” otherwise) Brief psychotic disorders…can be related to Obsessionality/anxiety Post-traumatic stress disorder Organic varilables Psychosis often occurs in bi-polar mania …. and adolescent depression 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 Bulimia Nervosa Bingeing Sense of loss of control
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) Treatment approaches: meal support, activity restriction, monitor electrolytes, EKG 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?
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… Build alliances (with permission, check in with, or at least wonder about, home/family, peers, primary doc, school staff, coaches, chaplain, etc) Your job is to help boost your patient’s adaptation and self-efficacy. Ask “What is going well for you ?” and “What are you/they worried about?” Help the kid look at their matrix of supports/influences. Assess patient’s risk management skills, use your motivational interviewing techniques. Be the “consultant”. Get the kid to be the lead investigator. Maintain alliance (availability for check ins, track attributions, follow strengths) Remember your own “serenity prayer”… Savor the camaraderie and access to hopes and humanity.


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