Billina R. Shaw, MD Assistant Professor University of Maryland School of Medicine Department of Psychiatry Division of Child and Adolescent Psychiatry Introductory discussion Prescribing trends in foster care youth The diagnostic assessment Overview of the medication evaluation Major psychotropic medication classes Role of the advocate in mental health care of 1
What is your first thought when you think of pediatric psychopharmacology? How do you feel about medicating children? What do you see as the role of medications in treatment? Sequence of treatment? Frequency of use? Etc? Medicaid populations disproportionately receive polypharmacy and antipsychotic medications Foster care youth are medicated at higher rates approximately 3 11 times higher than that of non foster care youth Children in foster care who receive at least one psychotropic medications are receiving three or more medications There remains a high degree of unmet need of children with mental health concerns 2
Why do you think this is the case? Too few child psychiatrists/prescribers Pediatricians wary of prescribing Too few therapists trained in evidenced-based therapies Many children and adolescents with mental health problems 3
Something happened that required them to be away from their family of origin Trauma Neglect They are away from their family Emotional and logistical implications 4
Obtaining diagnostic impression and formulation Learn about strengths and weakness of child Assess safety Build rapport with provider and/or agency Begin psychoeducation Begin to develop treatment plan May or may not include medication management Can be completed by a psychiatrist and/or LCSW C Requires an informed caretaker/guardian and the patient Typically an hour or more for the interview Will need additional time for registration, completion of paperwork, etc. May occur over more than one session 5
Inattention ADHD Depression Anxiety PTSD Intellectual Disability Hearing problems Language Disorder Oppositional Defiant Disorder 6
www.physio pedia.com Genetic predispositions Ie. ADHD In utero exposures Ie. Substances/Alcohol Developmental problems Toxins Ie. Lead poisoning Medical problems Ie. Hearing/vision problems 7
Temperament Thoughts Feelings Behaviors Psychological mindedness School Peers Trauma Family 8
Chief Complaint History of Present Illness Past Psychiatric History Medical and Psychiatric Review of Systems Family History Social History Developmental History Past Medical History Medications Allergies Assessment Plan 9
Chief Complaint History of Present Illness Open ended questions Closed ended questions 5 W s Review of systems ADHD ODD/Conduct Learning Disorders Depression Anxiety Trauma Past inpatient treatment Past outpatient treatment Past partial hospitalization or day program treatment Past medication trials 10
Mental Health Substance Abuse Suicides/attempts Learning Concerns School Repeated grades IEP School changes Learning concerns Peers Friends Bullying Family DSS involvement Trauma DJS involvement 11
Treatment options Medications Individual therapy Group therapy Family therapy School advocacy Children should come with an informed adult The guardian making medical decisions should be readily available Have the legal paperwork/court order Obtain and pass along medical and mental health records Attempt to have the child continue with the prior mental health/medical providers Continuity of care Attachment Ask questions 12
What is the role of the medication evaluation visit? 13
Continue to clarify diagnosis Engagement Initiate and monitor medications Monitor medication safety BP/heart rate Labs Treatment planning Therapy modalities PRP TBS Mentor Use of clinical interview, assessment/mse, objective scales, several sources (home, school, child) Obtained through learning the child/family, possible other collateral sources Not by reading a list of symptoms from the DSM May have to happen over time 14
Children will most likely have more than one diagnosis (or they go to the pediatrician) Recent physical exam to rule out medical causes Labs as necessary: thyroid studies, blood count, electrolytes, glucose, liver and kidney functioning, lead level Identify risks of treating and not treating Consider all settings (home, school, etc.) Consider developmental perspective Consider degree of evidence for the treatment Consider alternative treatments (pharmacotherapy and nonpharmacotherapy) 15
Situation dependent Mild depression v. school refusal Clinician comfort Parent and child comfort Other factors Each medication is different General Principles Start low Go slow Stop increasing when: Remission of symptoms Intolerable side effects 16
Monitor side effects Lower dose (or change to lower risk medication) after acute symptoms resolve Continue to monitor adherence Consider lowering dose or discontinuation annually Need to know Should be asked in a non assuming, nonjudgmental way Work to understand and address barriers Psychoeducation about illness, role of medication, transparency goes a long way Agree to disagree on medication plan sometimes and wait until the family truly desires pharmacotherapy Child won t take it anyway if they are not ready for pharmacotherapy 17
Assess and document the target symptoms of the current diagnoses Likely requires targeted questions Ask in the context of how the symptoms impair functionality Focus on change in symptoms and not necessarily just this point in time Have realistic expectations Some symptoms may never go away Ask parent and the child Every drug has a risk of side effects Ask about the common side effects Sleep Appetite Is the side effect worth stopping the med? Safety side effect v. comfort side effect Is the side effect related to the med? Obtain history of past med trials Effect, side effects Look for patterns of ineffective trials 18
Prepare, prepare & prepare Attempt at lower stress time Slow & gradual (with exceptions) If fails, try lowest dose possible Repeat when appropriate Ask about evidenced based treatments and other adjunct treatments Cognitive behavioral theapy Trauma focused models Assist in informed consent Assist in adherence 19
Major Classes of Medications for Children ADHD medications Antidepressants Atypical Antipsychotics Mood stabilizers 20
Stimulants Alpha agonists Straterra (atomoxetine) Wellbutrin 21
What is the role of stimulants in ADHD treatment? First line consideration 22
What percentage of children diagnosed with ADHD respond to stimulants? 23
70 80% Caveat: Most children in foster care have more than one diagnosis and decreases the effect size Stimulants Methylphenidate Dextroamphetamine 24
Decrease in appetite Weight and growth suppression Sleep disturbance High blood pressure Increased pulse Zoned or zombie look Dysphoric or irritable mood/affect Sudden Cardiac death? 25
Name some of the stimulants http://www.adhdmedicationguide.com Ritalin (shortest acting) Ritalin (LA/SR) Concerta (longest acting) Focalin (twice as potent) Metadate (CD/ER) Methylin (syrup/er) Daytrana (patch) Quillavant (long acting liquid solution) 26
Adderall (XR) Dexedrine (spansules) Vyvanse (prodrug/enantiomer) Procentra (liquid) 27
Rapid titration and effect Relatively safe Relatively well tolerated Can be used off label for aggression in absence of ADHD Risk of diversion Initially designed to lower blood pressure, but also have an effect on ADHD symptoms Less effective than stimulants Often used for sleep due to sedating properties Risk of diversion 28
Clonidine Guanfacine (tenex) Longer acting Kapvay (clonidine) Intuniv (guanfacine) Low blood pressure Low pulse Dangerous in overdose Sedation (clonidine > tenex) Rebound hypertension Pearl: Medications should be continued when a child goes in care 29
What is the role of alpha agonists in medication treatment of ADHD? 30
Adjunctive or alternative when stimulant not tolerated NE Reuptake inhibitor Less effective Takes weeks to work GI side effects (start low and go slow) Some potential side effects of stimulants and SSRIs Less abuse potential 31
Selective Serotonin Reuptake Inhibitor Increasing serotonin between nerve cells Other antidepressants work on Dopamine or Norepinephrine Can be effective on depression and anxiety Depressed children can be irritable and NOT depressed Antidepressants thereby can treat irritability Disruptive Mood Dysregulation Disorder is a Depressive Disorder 32
New Disorder in DSM 5 Severe recurrent temper outburst (verbal or physical) that are out of proportion to the stressor Developmentally inappropriate 3or more times weekly Persistent irritability between tantrums >12 months 2 settings Over age 6 Symptoms before age 10 33
Bipolar Disorder Oppositional Defiant Disorder DMDD trumps ODD if both criteria met Intermittent Explosive Disorder It should not ONLY co exist with or be better explained by other diagnoses like Major Depression, BUT they can be co diagnosed Another medical condition/substances Constructed from Severe Mood Dysregulation construct Previous consideration Temper Dysregulation Disorder with Dysphoria Comorbidity? ODD? Depressive Disorder? Stability of Diagnosis? Treatment? 34
Prozac (fluoxetine) Major Depressive D/O 8 yrs old OCD 7 yrs old Zoloft (sertraline) Major Depression and OCD 6 yrs old Lexapro (ecitalopram) Major Depressive D/O 12 yrs old Celexa (citalopram) Generalized Anxity, Major Depression, OCD 7 17 Cymbalta (duloxetine) Generalized Anxity and Major Depression 7 17 Paxil (Paroxetine) Wellbutrin (buproprion) Effexor (venlafaxine) Pristiq (desvenlafaxine) Remeron (mirtazapine) Tricyclics MAOIs 35
Most common = none GI discomfort, nausea (D&V=rare) Sexual Behavioral activation More common in younger children Agitation, restlessness, insomnia, impulsivity Disinhibition Black box warning on increased risk of suicide for all antidepressants used in children and adolescents Recommended monitoring guideline for suicidality (weekly for 4 wks, every other week for 4 wks, monthly) Such monitoring can be done by any mental health professional 36
1999 2007 claims database 44% decline in new dx of pediatric depression Decrease in SSRI prescribing No increase in psychotherapy Suicide rates for youth 10 19 increased from 2004 2007 SSRI or cognitive behavioral monotherapy: 1/3 to ½ will not have adequate improvement Placebo response is 24 57% in pediatric trials Modest effect sizes are similar to adult depression findings 40% who recover have another episode in 12 months 37
Typical and Atypical Dopamine blockade Atypical antipsychotics block dopamine as well as work on the serotonin receptor Atypical antipsychotic have less motor side effects Should not be first line unless for true psychosis or bipolar disorder Psychotic symptoms and mood lability overlap with many other diagnoses 38
What was the first atypical antipsychotic FDA approved for children? 39
What was the indication? 40
Risperdal Irritability associated with Autism Risperdal (Risperidone) Irritability associated with Autism 5 17 Bipolar Disorder. 10 17 Schizophrenia 13 17 Abilify (Aripiprazole) Schizophrenia. 13 17 Bipolar Disorder 10 17 Irritability with Autism 6 17 41
Seroquel (quetiapine) Schizophrenia 13 17 Bipolar 10 17 Zyprexa (olanzapine) Schizophrenia 13 17 Bipolar 13 17 Invega (paliperidone) Schizophrenia 12 17 Saphris (asenapine) Bipolar 10 17 Geodon (ziprasidone) Latuda (lurasidone) Clozaril (clozapine) 42
Haloperidine (haldol) Thorazine (chlorpromazine) Prolixin (fluphenazine) Extrapyramidal symptoms (EPS) Stiffness/dystonic reactions Often treated or prevented with benadryl or cogentin Can be dangerous if involving the airway Parkinsonism Tremor Tardive dyskinesia Abnormal involuntary movements of the body May be permanent 43
Neuroleptic malignant syndrome Symptom constellation of confusion, stiffness, vital sign changes Can be fatal Akathisia Internal drive to move Metabolic syndrome Obesity Diabetes Sedation/Dizziness Decreased blood pressure Dry mouth Constipation Gynecomastia and/or lactation Cardiac arrhythmia EKG for some medications 44
More susceptible to weight gain in weight neutral meds More susceptible to sedation Higher risk of EPS Generally preferred over classic mood stabilizers Abrupt discontinuation can cause withdrawal dyskinesias Labs AIMS Height, weight Diagnoses Psychosocial treatments 45
Very helpful in true bipolar mania True bipolar disorder in children is relatively rare Depakote (valproic acid) Primary indication is seizure disorder Lithium Naturally occurring salt Tegretol (carbamazepine) Seizure medication Trileptal (oxcarbazepine) Seizure medication Weight gain Gastrointestinal problems Sedation Rash Stevens Johnson syndrome may be fatal Decreases in blood count Liver problems Dangerous to fetus in pregnancy Polycystic ovarian syndrome Pancreatitis Tremor Hair loss Confusion Increased ammonia 46
Narrow therapeutic index Can be fatal/may require dialysis in overdose Nausea GI effects Dizziness Fatigue Tremor Thyroid problems Arrhythmia Increased thirst/urination Acne Hair loss Blood cell changes Increased white blood cell count Most require labs Therapeutic drug levels and monitoring for adverse effects Should not be first line unless true indication of bipolar disorder 47
Referral and support of all aspects of treatment including pharmacotherapy Facilitate discussion of Psychoeducation about illness and treatment plan Risks, benefits Concerns about medications Support of medication adherence An 8yo AAF presents upon referral from teacher to rule out ADHD. She sometimes does her work standing up, gets in trouble for talking too much, and has problems completing assignments Multiple strategies have been employed to aid in this including preferential seating and a behavior plan The plan works for 1 month, but the symptoms recur 48
The family is resistant to medications. How would you present medication management treatment to this family? Billina Shaw, MD bshaw@psych.umaryland.edu billinarose@hotmail.com 49
Dr. Gloria Reeves Dr. Mark Riddle Dr. Susan dos Reis No 17. Psychotropic Medication Use by Children in Child Welfare: Findings from the National Survey of Child and Adolescent Well Being Studyhttp://www.acf.hhs.gov/sites/default/fil es/opre/psych_med.pdf 50