behavior disorders in children NHUNG T. TRAN, MD, FAAP DEVELOPMENTAL-BEHAVIORAL PEDIATRICS SCOTT & WHITE HEALTHCARE ASSOCIATE PROFESSOR TEXAS A&M HEALTH SCIENCE CENTER COLLEGE OF MEDICINE VTRAN@SW.ORG MARCH 23, 2013 SCOTT & WHITE 22 ND ANNUAL ROBERT E. MYERS, MD, LECTURESHIP IN PEDIATRICS
faculty disclosure Discussion will reference some pharmaceuticals that are not approved by the FDA for use in children and adolescents. I have no relevant financial relationships with the manufacturer(s) of any commercial product(s) and/or provider of commercial services discussed in this CME activity.
objectives To better recognize typical from atypical behaviors To know behavioral screening tools and how they can be used in clinical practice To understand the management of some behavioral disorders
the whole child HPI: severely hyperactive, impulsive, aggressive, not learning FHX: maternal grandmother is alcohol-dependent drinker; mother is at-risk drinker and has mild ID Prenatal HX: daily binge drinking until 5 months gestation, in an effort to abort mary
the whole child Features Partial FAS Phenotype Developmental Behavioral Medical Intellectual Disability, Language Disorder ADHD, ODD, insomnia Growth 10 th percentile Motor Psychosocial Fine motor deficits, dysgraphia Poor social cognition, parentchild conflicts
the whole child Treatment Partial FAS Phenotype Developmental Behavioral Medical Special Education under OHI, MR and SI ; ST Medications, counseling Close monitoring Motor Psychosocial OT (school) Social skills training; maternal mental health; case management
extrinsic and intrinsic factors Maternal depression Parental attitude Parenting stress Parent characteristics Parenting style Behavior problem Child characteristics Poverty Social network Maternal education Socio- Economic Temperament Medical disability Cognitive disability Behavior disorder
behavior disorders in children Why did he do that? Should I be worried? What is going on? What should I do?
why did he do that? A-B-C S OF BEHAVIORS
taking the behavioral history in the eyes of the beholder misery loves company
why did he do that? result in self-injury, injury to others, cause damage to the physical environment and/or interfere with the acquisition of new skills, and/or socially isolate the learner [Doss & Reichle, 1991] Described by Form Function Social motivation
why did he do that? Form Single form per episode Sequence or group of behaviors per episode Function To communicate, especially emotion To avoid or escape undesired/nonpreferred outcomes (attention, objects, activities) To gain access to desired/preferred outcomes (attention, objects, activities)
why did he do that? Social motivation - what is needed to affect the probability that behaviors will continue to occur in the future Socially motivated: requires others in the environment Non-socially motivated: does not require others in the environment, often to gain access to or avoid/escape internal stimuli
why did he do that? Ex. Ben with quadriplegic CP and severe dysarthria slaps himself in the face until the teacher takes him to the playground Form: self-injury Function: gain access to desired activity (i.e., play) Socially mediated: teacher positively reinforces the inappropriate behavior
why did he do that? Ex. Noah likes to bang objects to make loud noises Form: making loud noises (disruptive) Function: gain access to desired outcome (sensory) Non-socially motivated: sensory stimulation positively reinforces the inappropriate behavior
why did he do that? Ex. Beth bangs her head with an ear infection. Mom picks up to soothe, offers toys, goes to the doctor. Now Beth bangs her head often. Form: self-injury Function: gain access to desired outcome (mom s attention) Non-socially motivated: decreased pain positively reinforces inappropriate behaviors Socially motivated: mom s attention further positively reinforces behavior
why did he do that? Ex. Kristin tantrums each time the teacher begins to work with her classmates Form: tantrums Function: gain desired outcome (i.e., teacher attention) Q: What would positively reinforce this behavior? Q: What would negatively reinforce this behavior?
why did he do that? Antecedents Setting events (context)? Antecedent stimulus (trigger)? Behaviors Response to stimulus? Consequences Maintaining consequence (reinforcers)?
should I be worried? TYPICAL VERSUS ATYPICAL SCREENING
should I be worried? When it s too odd, too often, too much Hyperactivity-impulsivity Anxiety Obsessive-compulsive behaviors Mood problems Aggression (verbal and physical) Self-injury
should I be worried? first stage screening second stage screening Brief Infant-Toddler Social & Emotional Assessment (BITSEA) Ages & Stages: Social-Emotional (ASQ:SE) Pediatric Symptom Checklist (PSC) Eyberg Child Behavior Inventory (ECBI) Pediatric Intake Form (a.k.a., Family Psychosocial Screen)
Pediatric Symptom Checklist General psychosocial screen [Jellinek, MD; Murphy, EdD] Ages 4-16 years Parent & self report (>9 years old) 35 items 7 minutes English, Spanish and many others Provides cut-off (including Attention, Internalizing, Externalizing subscales) Sensitivity 80-95%; specificity 68-100% www.massgeneral.org/psychiatry/services/psc_home.as px
should I be worried? When it s not within normal limits first stage screening second stage screening
should I be worried? first stage screening second stage screening Child Behavior Checklists (CBCL, TRF, C-TRF, YRF) Behavior Assessment Scale for Children, Second Edition (BASC-2) Infant-Toddler Social & Emotional Assessment (ITSEA)
what is going on? EVALUATION
what is going on? Appropriate referral for evaluation Evaluation consists of History Key clinical questions Clinical interview or observation Standardized questionnaires Differential diagnosis DSM-IV-TR criteria
standardized questionnaires ADHD: NICHQ Vanderbilt Assessment Scale Conners, 3 rd Edition (Conners 3) ADD-H Comprehensive Teacher s Rating Scale (ACTeRS), Second Edition Others: See attachment from Massachusetts General Hospital http://www2.massgeneral.org/schoolpsychiatry/screeningt ools_table.asp
what should I do? MANAGEMENT
multimodal management Developmental assessment/supports Environmental assessment/supports Functional behavioral analysis Parenting skills Educational supports Behavioral and other therapies Psychopharmacotherapy
specific disorders ADHD ODD ANXIETY DISORDERS MOOD DISORDERS
ADHD overview signs & symptoms differential diagnosis diagnosis management pearls & pitfalls 4-6% prevalence Higher in lower SES Male:female estimated at 2:1 Etiology Genetic factors Medical risk factors Prognosis Symptoms persists into adulthood, but change over time Better if treated, no co-morbid behavior disorders, higher IQ, higher SES
ADHD overview signs & symptoms differential diagnosis diagnosis management pearls & pitfalls Presentation: ADHD-IA: academic problems ADHD-HI: conduct problems ADHD-CT: both 3-5 years 6-8 years ADHD-CT, -HI ADHD-IA severe mild home school social +/- safety +/-
ADHD overview signs & symptoms differential diagnosis diagnosis management pearls & pitfalls Clinical observation* Physical examination* Diagnosis is by DSM-IV-TR criteria Other studies if indicated: Psychoeducational if learning disability suspected Neurological (e.g., EEG) if neurological condition suspected * Often not helpful
ADHD overview signs & symptoms differential diagnosis diagnosis management pearls & pitfalls Pharmacologic mainstay Stimulants Atomoxetine Alpha-agonist Certain atypical antidepressants Guidelines Texas Children s Medication Algorithm Project [Pliszka et al, 2006] Psychopharmacological Treatment for Very Young Children [Gleason et al, 2007]
Pliszka et al, JAACAP, 2006, 45(6): 642
Pliszka et al, JAACAP, 2006, 45(6): 642
ADHD medication guide www.adhdmedicationguide.com
ADHD overview signs & symptoms differential diagnosis diagnosis management pearls & pitfalls Non-pharmacologic Parenting (or parent training) especially in preschool aged children Psychotherapy if co-morbidity Complementary & alternative Refer if Not responsive to medications Persistent, unacceptable side effects Diagnosis is not clear
ADHD overview signs & symptoms differential diagnosis diagnosis management pearls & pitfalls Diagnostic certainty is impossible Co-morbidities are common Myths and misconceptions are common Goal is reducing morbidities (home, school, social, safety) Be familiar with the pharmacokinetics Care coordination improves prognosis
ODD overview signs & symptoms differential diagnosis diagnosis management pearls & pitfalls Recurrent pattern of negativistic, disobedient, hostile behaviors 2-16% prevalence Higher in males Etiology Genetic factors (slight) Environmental factors (significant) Temperamental factors (significant) Co-morbidities Behavioral: ADHD, mood, conduct Developmental: language disorders
ODD overview signs & symptoms differential diagnosis diagnosis management pearls & pitfalls Presentation Onset<3 years old, increases with age Worse in>out of the home Symptoms Tantrums Persistent stubbornness Resistance to directions Inflexibility Deliberate, persistent testing of limits Verbal>physical aggression Labile mood Low frustration tolerance Low self-image
ODD overview signs & symptoms differential diagnosis diagnosis management pearls & pitfalls Clinical observation (in vitro)* Physical examination* Diagnosis is by DSM-IV-TR criteria Other studies if indicated: Speech-language if speech-language disorder suspected Psychoeducational if developmental or learning disability suspected * Often not helpful
ODD overview signs & symptoms differential diagnosis diagnosis management pearls & pitfalls Advice on behaviors* Rather, focus on other anticipatory issues (e.g., exposure to violence) Counseling mainstay Psychologist Licensed professional counselor Goal is to reduce symptoms Parenting (or parent training) Family therapy Cognitive-behavioral therapy Collaborative problem solving (Pharmacologic) * Often not helpful
anxiety disorders overview signs & symptoms differential diagnosis diagnosis management pearls & pitfalls 13% prevalence Most common psychiatric disorder 33% have 2 other anxiety disorders Etiology: Genetic factors Environmental factors Temperamental factors Prognosis: Often chronic, persistent into adulthood
anxiety disorders overview signs & symptoms differential diagnosis diagnosis management pearls & pitfalls Types: Simple phobia (10-11%) Generalized anxiety disorder (3-10%) Obsessive compulsive disorder (2.5%) Separation anxiety disorder (4%) Social phobia (10-11%) Generalized versus non-generalized Selective mutism Posttraumatic stress disorder (1-14%) Panic disorder (1.5-3.5%)
anxiety disorders overview signs & symptoms differential diagnosis diagnosis management pearls & pitfalls Presentation: Cognitive catastrophic thoughts, poor school performance Physical nausea, pain, headaches, eating problems, sleeping problems Emotional fears, worry Behavioral avoidance, escape, emotional outbursts Ask about Duration, frequency, intensity Anticipatory vigilance?
anxiety disorders overview signs & symptoms differential diagnosis diagnosis management pearls & pitfalls DDX: Developmentally appropriate worries and fears Medical conditions (due to somatic complaints) Medication side effects Learning d/o (e.g., school refusals) Developmental d/o (resulting in younger mental age)
anxiety disorders overview signs & symptoms differential diagnosis diagnosis management History Clinical observation* Physical examination* DSM-IV-TR criteria Other studies if indicated: Medical evaluations to rule-out medical condition pearls & pitfalls * Often not helpful
anxiety disorders overview signs & symptoms differential diagnosis diagnosis management pearls & pitfalls Non-pharmacologic mainstay Parenting (or parent training), for children <8 years old Cognitive-behavioral therapy, for children >8 years old Pharmacologic When severe impairment in functioning Options: SSRI, atypical antidepressants, (benzodiazepines) Educational Supports Special Education under Emotional Disturbance
anxiety disorders overview signs & symptoms differential diagnosis Internalizing disorders are easier to under-recognize Often co-morbid externalizing disorders Have more contextual clues diagnosis management pearls & pitfalls
depressive disorders overview signs & symptoms differential diagnosis diagnosis management pearls & pitfalls 1-8% prevalence Etiology/risk factors: Genetic Environmental Neurodevelopmental factors/stages Medical 60-80% co-morbidities Types: Major Depressive Disorder Dysthymic Disorder
depressive disorders overview signs & symptoms differential diagnosis diagnosis management pearls & pitfalls Depressive episode: 2 weeks of 5 symptoms of: *Depressed mood *Markedly diminished interest or pleasure Significant weight loss or gain, or decrease or increase in appetite Insomnia or hypersomnia Psychomotor agitation or retardation Fatigue or loss of energy Feelings of worthlessness or excessive or inappropriate guilt Diminished ability to think or concentrate, or indecisiveness Recurrent thoughts of death, recurrent suicidal ideation, or suicide attempt
depressive disorders overview signs & symptoms differential diagnosis diagnosis management pearls & pitfalls Presentation: Infants/toddlers passive & unresponsive to irritable & inconsolable School aged irritability, withdrawn, somatic, morbid preoccupation Adolescents intense negative feelings, leading to irritability, anger, resentment, and self-harm DDX: Medical conditions Substances
depressive disorders overview signs & symptoms differential diagnosis diagnosis management pearls & pitfalls History Direct, private discussion with children and adolescents Clinical observation Physical examination* DSM-IV-TR criteria Other studies if indicated: Medical evaluations to rule-out medical conditions, substances * Often not helpful
depressive disorders overview signs & symptoms differential diagnosis diagnosis management pearls & pitfalls Setting Primary care provider for mildmoderate depression Mental health professionals for moderate-severe depression Immediate psychiatric evaluation if suicidal, psychotic, abusing substances Non-pharmacologic mainstay Counseling Psychosocial interventions Pharmacologic SSRI, (TCA)
bipolar disorder overview signs & symptoms differential diagnosis diagnosis management pearls & pitfalls True prevalence unknown Etiology/risk factors: Genetic Neurodevelopmental factors/stages Environmental 60-80% co-morbidities ADHD, conduct disorder, anxiety, substance abuse Prognosis Typically chronic, lifelong Often partial recovery, frequent relapse
bipolar disorder overview signs & symptoms differential diagnosis diagnosis management pearls & pitfalls Manic episode: 1 week of 3 symptoms of Abnormal mood: euphoria + irritability (extreme, persistent, threatening, out-ofcontrol, rages) Distractibility Increased activity/energy Grandiosity Flight of ideas Activities with bad outcome Sleep decreased Talkativeness Can be Mixed, Hypomanic episodes
bipolar disorder overview signs & symptoms History Clinical observation Physical examination* DSM-IV-TR criteria differential diagnosis diagnosis management pearls & pitfalls * Often not helpful
bipolar disorder overview signs & symptoms differential diagnosis diagnosis management pearls & pitfalls Goal: Control mania (and depression) Develop insight Adhere to medications, prevent relapse Address co-morbidities Pharmacologic mainstay Mood-stabilizers Combined treatments typically needed Non-pharmacologic Counseling
bipolar disorder overview signs & symptoms differential diagnosis Mood-stabilizers Atypical antipsychotics Lithium Certain anticonvulsants (valproate, carbamezapine, oxycarbamezapine, lamotrigine) diagnosis management pearls & pitfalls
bipolar disorder overview signs & symptoms differential diagnosis diagnosis management pearls & pitfalls Pediatric mania is More irritability than euphoria More mixed states and complex cycling More chronic More co-morbidities Parenting does not cause BPD Parents may see it first Antidepressants, stimulants can exacerbate mania
stimulants Generic methylphenidate dexmethylphenidate Brand Ritalin, Ritalin SR, Ritalin LA Metadate CD, Metadate ER Methylin, Methylin ER Concerta, Daytrana Focalin, Focalin XR dextroamphetamine Dextrostat, Dexedrine, Dexedrine spansules amphetamine salts Adderall, Adderall XR
2 adrenergic agonists Generic Brand clonidine Catapres, Kapvay guanfacine Tenex, Intuniv noradrenergic reuptake inhibitpr Generic Brand atomoxetine Strattera
SSRI antidepressants Generic Brand T 1/2 Steady state fluoxetine Prozac 24-72 hrs 5 weeks paroxetine Paxil 21 hrs 7-10 days sertraline Zoloft 26 hrs 7-10 days fluvoxamine Luvox 16 hrs 7-10 days citalopram Celexa 36 hrs 7-10 days escitalopram Lexapro 27-32 hrs 7-10 days SSRI = selective serotonin reuptake inhibitor
atypical antidepressants Generic Brand buspirone Buspar clomipramine Anafranil bupropion Wellbutrin, Wellbutrin XR mirtazapine Remeron venlafaxine Effexor, Effexor XR imiprimine Tofranil nortriptyline Pamelor nefazodone Serzone trazodone Desyrel
atypical neuroleptics Generic Brand risperdone (H) Risperdal olanzepine (M) Zyprexa quetiapine (M) Seroquel aripiprazole (L) Abilify ziprasidone (M) Geodon clozapine (L) Clozaril L=low potency; M = medium or intermediate potency; H=high potency
antiepileptic & mood stabilizers Generic Brand lithium carbonate Lithobid carbamazepine Tegretol oxcarbazepine Trileptal valproate Depakote lamotrigine Lamictal gabapentin Neurontin topiramate Tpopmax clonazepam Klonopin
final comments Your role is helping decide typical from atypical. There are tools available to you. Make the diagnosis. Manage the condition.