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 ObjectivesThis 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.MickLecture goals:Discuss problem/risk prevalenceDiscuss explanatory and intervention challenges in child mental healthReview research status of interventions…Augmenting the Andreason/Black textbook chapter on Child Psychiatry
4 Peds Psych …OLD Diagnostic Categories (DSM-IV) Autistic Spectrum DisordersAutism, Asperger’s Disorder, Pervasive Developmental DisorderLearning DisordersReading Disorder, Mathematics Disorder, Disorder of Written ExpressionDisruptive Behavior and Attentional DisordersADHDOppositional Defiant Disorder, Conduct disorderMood and Anxiety DisordersMajor depression, Dysthymic Disorder, Bipolar DisorderPost Traumatic Stress Disorder, Obsessive Compulsive DisorderGeneralized Anxiety Disorder, Panic Disorder, Social Anxiety, Specific PhobiasSomatoform DisordersConversion Disorder, Pain Disorder, Body Dysmorphic Disorder, Somatoform DisorderEating disordersAnorexia Nervosa, Bulimia Nervosa, Eating Disorder Not Otherwise SpecifiedThought DisordersSchizophrenia, Schizophreniform Disorder, Psychotic DisorderSubstance Use DisordersAbuse, Dependence, Intoxication, WithdrawalPlesae 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 DisordersIntellectual DisabilitiesAutistic Spectrum DisorderLearning disordersAttention-Deficit/Hyperactivity Disorder (removed from “disruptive” disorders)Schizophrenia Spectrum and Other Psychotic DisordersSchizophrenia, Brief Psychotic, Schizotypal Disorder, Psychotic Disorder due to medical conditionsBipolar and Related disorders, Depressive disordersAnxiety DisordersGeneralized Anxiety, Panic Disorder, Social Anxiety, Specific PhobiasObsessive Compulsive DisorderTrauma- and Stressor-Related Disorders (now a separate category from anxiety disorders)Somatic Symptom and Related DisordersIllness Anxiety Disorder, Conversion DisorderFeeding and Eating DisordersAnorexia Nervosa, Bulimia Nervosa, Avoidant/Restrictive Food IntakeDisruptive, Impulse Control, and Conduct DisordersOppositional Defiant Disorder, Intermittent Explosive Disorder, Conduct disorderSubstance 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
7 Childhood differences (from adult dx)… Symptoms & Frequent Comorbidities(using pediatric depression as an example)Pediatric DepressionAdditional SymptomsIrritability: often 1º symptom40% - 70% with Comorbid DiagnosisTemper tantrumsMood labilityAnxiety disorders: 20% - 40%Low frustration toleranceSubstance misuse: 20% - 30%Disruptive behavior and neruodevelopmental disorder (incl. Conduct disorder /ADHD/learning disorders): 10% - 80%Somatic complaintsGuiltLow self-esteemSuicidal ideation (60%)Suicide attempts (30%)Natural History:OppositionalMedian episode: 1 – 8moSocial isolationRecurrence: 20% - 60%Bipolar Disorder: 20% - 40%Kids depressive profiles are different from adults…
8 Nonspecific Symptoms (example of continua and overlap between sx…) ManiaIrritabilityIncreased EnergyPressured SpeechReckless BehaviorGrandiosityDistractibilityDecreased SleepADHDGrumpyHyperactiveTalking FastReckless BehaviorBraggingDistractibilityRestless 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 communityThe trauma is held personally and collectively and is transmitted over generationsDistress generated from historical trauma is often unrecognized, misunderstood, ignored, marginalized, or invalidatedBrave Heart (1995); Yellow Horse Brave Heart (2000)
10 Child Psychiatry: Epidemiology 5 to 15 percent with clinically significant disordersBelow age 12 years: Boys outnumber girls,Higher rates of behavioral/learning/developmental disorders12 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 schoolsTotal sample size = 16,410School-level response rate = 81%Student-level response rate = 88%Overall response rate = 71%National survey every two yearsSome 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 morbidityUnintentional injuries and violenceTobacco useAlcohol and other drug useSexual behaviorsUnhealthy dietary behaviorsInadequate physical activityObesityAsthmaThe 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… MickThis 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,‡ 2009Nationwide 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 > BNational 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. 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,§ 2011In 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 > BNational 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 < 0.05National 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 < 0.05National 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,† 2009Nationwide 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 > BNational 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 times28. 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 < 0.05National 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 suicideSuicidal ideation very common inadolescents: 20% per year4. Suicide attempts: YRBS says 6% per year…wow!a. Attempts are much more common in femalesb. Suicides are much more often completed in males5. 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.
34 Suicide Rate, 15-24 year-olds 29% declineTotalFirearmSuffocation PoisonOtherThis 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 studiesMinimal literature examining combined therapies and polypharmacyLimitations include small sample sizes, lack of controls, narrow diagnostic inclusion criteria and short duration of treatmentMost 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 BodyBiofeedback –yoga,sportsThoughts about actionsThe phone call from grandmaSongsMeal milieuMedia imagesThe meaning of the medication toThe youthThe parentsThe teachersThe peersSleep hygieneActivities change cortisol & testosterone levels, etcFresh air and romping aroundDiet
37 FDA APPROVED- Peds psych meds Attention-deficit Hyperactivity DisorderObsessive-Compulsive DisorderSertraline (≥6yo)All amphetamine and methylphenidate formulations (≥6yo)Fluoxetine (≥7yo)Fluvoxamine (≥8yo)Clomipramine (≥10yo)Dexedrine IR (≥3yo)Bipolar DisorderAtomoxetineRisperidone (≥10yo)Guanfacine ERClonidine ERAripiprazole (≥10yo)Quetiapine (≥10yo)AggressionLithium (≥12yo)Risperidone & Aripiprazole for aggression associated with autismOlanzapine (≥13yo) – acute treatment onlyMajor DepressionSchizophreniaFluoxetine (≥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-medicationPotential for sudden death and cardiovascular problems with stimulants? Over-diagnosis? Enhanced appreciationAAP no longer recommends routine pre-treatment cardiogramsSince 2003, FDA has issued separate warnings regarding increasedWashington State House Bill 1088DSHS required to monitor psychotropic use in youthSuicidal Ideation:AntidepressantsAtomoxetineAntiepilepticsMetabolic DiseaseAtypical antipsychotics
41 StimulantsShort Term Effectiveness of Stimulants for ADHD well documentedOver 200 published Randomized Control Trials (RCT), including studies with preschoolers and adultsMethylphenidate best studied, followed by dextroamphetamine and mixed amphetamine salts65 – 75 % response rate, compared to 5 – 30 % placebo responseAll stimulants equally effectiveExcept methylphenidate more effective if comorbid autismFDA approval for ADHDAge 6 for all, age 3 for DEXFDA Black Box Warning for amphetamine salts due to cardiotoxicity removedExtended-release preparationsTransdermal methylphenidateD-threo methylphenidateLisdexamfetamine(Meth)amphetamine meanings?
42 α – Adrenergic Agents for “Autonomic Reactivity” -for kids who can’t “pull” their punches -hypervigilance -overarousalα2 – Adrenergic Agonists: Several small RCTs show efficacy in ADHD TxClonidine/GuanfacineFDA 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…PrazosinPTSD nightmares
43 Uses for Selective Serotonin Re-Uptake Inhibitors in Youth DepressionDysthymiaBipolar DepressionGeneralized AnxietySeparation Anxiety DisorderPanic DisorderObsessive Compulsive DisorderPost-Traumatic Stress DisorderAutism Spectrum DisordersChronic Headaches or Pain
44 SSRIs for Depression Response rates 40-70% and Placebo rates 30-60% Fluoxetine: First studied, Most consistent positive resultsOnly FDA-approved medications for pediatric depression:Fluoxetine ≥ 8yoEscitalopram ≥ 12yoFDA Black Box Warning: Increased suicidal ideationIncreased risk of suicidal ideation during the first few months of treatment4% for active medication vs 2% for placeboNo increase in suicide attemptDebatable - ?increased suicide attempts concurrent with reduction in SSRI prescriptionsFDA 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 OCD4 Positive RCT’s, including two multisite trialsFluvoxamine, Sertraline and Fluoxetine all found effectiveAll FDA-approved for Tx of pediatric OCD
46 Tricyclic Antidepressants Imipramine, Amitriptyline, Nortriptyline, Clomipramine, Desipraminethe old guard….not used much nowDepression: 13 studies, > 300 subjects: none were superior to placebo (50 – 60 % placebo response rates)ADHD: several positive RCT’s, although not as effective as stimulantsEnuresis: several positive RCT’s for ImipramineOCD: 3 positive RCT’s for Clomipramine, 1 RCT found Clomipramine helpful for repetitive behaviors in autismBest 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 OCDMild symptoms typically remit within 4-6wks with psychotherapy aloneHigh placebo response ratesExpect spontaneous remission when treating mild depression“Placebo” is not equivalent to “no treatment”Limited long-term dataBias in pharmaceutical industry sponsored studiesResponse: No symptoms or a significant reduction indepressive symptoms for at least 2 weeks• Remission: A period of at least 2 weeks and <2 monthswith no or few depressive symptoms• Recovery: Absence of significant symptoms of depression(e.g., no more than 1Y2 symptoms) for Q2months• Relapse: A DSM episode of depression during theperiod of remission• Recurrence: The emergence of symptoms of depressionduring 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-WeekStudy.Scores on the Pediatric Anxiety Rating Scale range from 0 to 30, with scoreshigher than 13 consistent with moderate levels of anxiety and a diagnosisof an anxiety disorder. The expected mean score is the mean of the samplingdistribution 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 abuseTwo positive, one negative RCTs for Disruptive Behavior/AggressionLarge Open Label Trial (Kafantaris et al., 2003) (n = 100) had a 63% response rate in adolescents with Bipolar I DisorderOpen 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 suicidalityValproate – weight gain/rash/lPCO disease/liver & heme SEslimited efficacy…maybe some benefit for borderline personality regulationLamotrigineEffective In Adult Studies of Bipolar DepressionOpen label study supports use in adolescents with bipolar depression (Chang et al., 2006) worry about Stevens Johnson syndrome/rashOxcarbazepineFew Adult Studies Show EfficacyNegative Trial in Youth (Wagner et al. 2006)CarbamazepineAdult Studies Not as Robust as for VPATopiramateNegative adult trials, …..cognitive bluntingInconclusive support for youth (Delbello et al, 2005)GabapentinLarge Controlled Trial in Adults was negative
52 AntipsychoticsAtypical antipsychotics provide the largest profit to pharmaceutical companiesMolindone vs. Olanzapine and RisperidoneAs effectiveFewer metabolic side effects1/10th the costNo longer produced!Significant adverse effects associated with all atypical antipsychoticsYouth more susceptible to metabolic adverse effects than adults
53 Atypical Antipsychotics FDA indications for PediatricsRisperidoneIrritability for children and adolescents with AutismAdolescents with SchizophreniaAdolescents with Bipolar DisorderAripiprazole
54 Peds Psychopharm Summary We generally treat symptom clusters that span a variety of domains of functioning and presentations of distressSome RCT evidence for:Antipsychotics for aggression associated with autism spectrum disordersDomains: Cultural and Social Expectations, Social and Physical Environment, Identity, Behavioral Norms, Emotional Norms, Perceptions, Learning SystemsAlpha-agonists for ADHD symptoms, primarily as adjunctiveSymptom clusters: Thought Organization, Mood Regulation, Attentional /Impulse Control Capacity, Social RelatednessVery little study of polypharmacy interventionsSubstantial Empirical Evidence Currently Supports:AND polypharmacy increasingly commonCombination of psychotherapy and psychopharmacologyStimulants for ADHDSSRIs for Depression and OCDLithium for Bipolar DisorderAntipsychotics for Psychosis
55 Psychotherapeutic Interventions Existing Evidence Suggests Traditional Therapies Most Often Used are Not Clearly Effective …butDialectical 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 DepressionAt least 10 Positive RCTs for Depression in Children and AdolescentsComparison arms included wait list controls and nondirective supportive psychotherapyAnxietyIndividual and Family CBT approaches found useful for Separation Anxiety and Generalized Anxiety DisordersBehavioral Strategies useful for PhobiasOCDsome positive trials in kids, well established efficacy in adultsmore robust support for “combination therapies”PTSDPositive 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 TrainingAnger ManagementAssertiveness TrainingADHD – specific interventionsInconsistent findings with strategies designed to improve self controlNot much data on “neurofeedback” (fun to think about though)…Contingency Management and Behavioral Interventions helpfulGenerally not as powerful effects as stimulants.Time Consuming, difficulty with complianceDon’t always generalize to other settings or beyond the treatment
58 Rising stars in therapy for kids Trauma focused-Cognitive Behavioral TherapySponsored locally by the Harborview Sexual Assault CenterCustomizable modules…core construct: boosting resilience through the “trauma narrative”, helping families build safety zonesMotivational Interviewing:Mentoring child, adolescent and family forays through their “risk grids”Showing up, now, in a range of pediatric challenges includingDiabetes co-management, toddler sleep cycles, breast-feeding challengesDialectical Behavioral Therapy:Individual and group componentsModified to fit for early teens, kids with developmental disabilities …Distress tolerance strategiesMindful practice
59 TRAUMA-FOCUSED COGNITIVE-BEHAVIORAL THERAPY Manualized Individual, Parent, and Conjoint TherapyTargets:Post-traumatic Stress SymptomsDepression, anxiety, and behaviors resultant from PTSGoals:Eliminate symptoms PTSDevelop parenting comfort and skills confronting child’s PTS symptoms
60 TF-CBT METHOD P: Psychoeducation, Positive Parenting R: Relaxation TechniquesA: Affective Expression and ModulationC: Cognitive Coping and ProcessingT: Trauma NarrativeI: In vivo ExposureC: Conjoint Child-Parent SessionsE: Enhancing Future Safety and DevelopmentPermanent, pervasive, too personalizedAccurate and Helpful?Regret and ResponsibilityIn Vivo Exposure when appropriate to reduce traumatic reminders
61 Parenting Training Programs Oppositional/Conduct DisorderInterventions Designed to enhance parenting effectiveness, decrease coercion and improve parent-child interactions, includingBehavioral Family Intervention (Patterson 1974)Videotaped Modeling Parent Training (Webster-Stratton 1994)Parenting Interventions and Family Therapy also helpful forAnxiety DisordersEating DisordersEarly 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 systemsMST has better outcomes (including reduced substance abuse) and more cost-effective thanHospitalizationIncarcerationHowever, effects may dissipate over months (Henggeler et al., 2003)
63 Psychotherapy In Children and Adolescents: Summary Best Evidence forCBT for Depression, Anxiety, PTSDCBT/behavioral strategies for conduct problemsParent Training for preschool challenges and conduct problemsMST for Conduct ProblemsDespite the availability of these InterventionsMost clinicians not systematically trained to use themMost 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” disorderChanging the age of onset developed in DSM-IV (from 7 to 12?)Fewer symptoms required for a diagnosis of adult ADHDPTSD was taken from the “Anxiety” disorders category and given it’s own realmAutism 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 detailscan’t keep on taskdoesn’t seem to listen when spoken todoesn’t follow through with instructionsdifficulty organizingreluctant to put in effort for school or homeworkoften loses things necessary for activitiesis easily distractedis forgetful
66 ADHD Criteria: Hyperactivity-impulsivity Six or more of the following for >6 mosMust be maladaptive and inconsistent with developmental ( level)Hyperactivityoften fidgets with hands or feet or squirms in seatoften climbs or runs about … or feels restlessdifficulty playing or engaging in leisureoften leaves seat when expected to remain in seatoften is “on the go” or acts as if “driven by a motor”often talks excessivelyImpulsivityoften blurts out answers before questions completely askedhas difficulty awaiting turnoften interrupts or intrudes on others
67 Bipolar Disorder Prevalence of Bipolar Disorder Debated Most disruptive, irritable children do not have bipolar disorderNew 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 DebatedEstimates range between 0.4% - 6%, depending on symptom severityBest estimate adolescent prevalence similar to adult: 1%0.3% - 0.5% adults with bipolar had symptom onset before 10yoPeak incidence between 15 – 30yoPsychosis with mania, frequent mood switching, and comorbidity with ADHD are commonUnclear how youth symptoms associated with adult course
68 Conduct /Oppositional Defiant Disorder Oppositional Defiant Disorder: …for six monthsNegativistic, pain in the …Loses temper, arguesDefiesDeliberately annoys/easily annoyedAngry, resentful, spitefulWonder about the family variablesConduct Disorder : 3 or more in the last 12 mos. of behaviors likeTruancy, runawaysAggression to people animalsDestruction of propertyDeceitfulness/theftSerious 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 Attachmentrelated to extreme/insufficient care….significant impact on affiliationdebate on how to constue this after age 5Posttraumatic Stress DisorderDSMV now has appreciation of special early childhood featuresRe-experiencing phenomena (flashbacks, nightmares) as with adultsAvoidance and trust issues…Re-enactment issues can be very different from adults…Look at play themesConduct regulation
70 Psychosis in children and adolescents Schizophrenia is much rarer than in adultsHallucinations in pre-adolescents are often anxiety (including PTSD) phenomena(until “proven” otherwise)Brief psychotic disorders…can be related toObsessionality/anxietyPost-traumatic stress disorderOrganic varilablesPsychosis often occurs in bi-polar mania…. and adolescent depressionOrganic contributorsNeurologic/endocrineEating disordersAutistic spectrum strugglesSevere 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 communicationDeficits in nonverbal communication skillsFailure to develop appropriate peer relationshipsLack of social understanding, interests, reciprocityRestricted repetitive and stereotyped patternsof behaviorPreoccupation with idiosyncratic interestsInflexible adherence to routines/rulesStereotypic motor mannerismscan occur with or without intellectual or language impairmentsSeverity:Level 3 – requiring very substantial supportsLevel 2 – requiring substantial supportsLevel 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 intakeIntense fear of gaining wtDisturbance in way body wt is experienced10:1 female/male ratioNo longer a criterion regarding missed menstrual cyclesseverity based on BMI…contemplate the role of “the web” and social media(con and pro)Treatment approaches: meal support, activity restriction, monitor electrolytes, EKGBulimia NervosaBingeingSense of loss of controlAt least once a wk for 3 mos.Self-evaluation is unduly influenced by body shape/weightBe mindful of frequency of transient eating problems
74 Resilience What protects some kids? temperament (arousal patterns/mood template)cognitive profilebirth orderspecific ties inside or outside the “family”locus of control, well played age-specific defensesfinding someone at the right timeluck 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.