ADHD and Beyond Shaw Wendi Fortuchang, M.D. Board certified in Child & Adolescent, Adult, and Forensic Psychiatry
Overview Use of medications in children How do medications work in the brain? Risperdal? Polypharmacy (multiple medications)? How much is too much? Best ones for Anxiety Disorders? Best ones for Depressive Disorders? ADHD? What works best and with the fewest side effects? Diagnosis of psychiatric disorders in children Most common diagnoses? Early diagnosis? How to differentiate amongst similar diagnoses Hallucinations in young children Do rating scales help? How can psychologists and other therapists help assist MD in the diagnosis?
4 Major Anatomic Systems Thalamus Relays sensory information to the cortex Association cortex Sensory information processing Medial temporal lobe Including hippocampus and amygdala Basal ganglia Voluntary motor movements
Neuron
Neurons (Nerve Cells) Cell Body Where neurotransmitters and other proteins are made Axon the output station of the cell Dendrites Provides the cell body with input from other cells
4 Major Neurons Cholinergic neurons (acetylcholine) In basal forebrain and brain stem Dopaminergic neurons (dopamine) In substantia nigra and ventral tegmental area Noradrenergic neurons (norepinephrine) In locus ceruleus Serotonergic neurons (serotonin) In raphi nuclei
Acetylcholine Modulates attention, novelty seeking and memory Anticholinergic delirium and Alzheimer s Dementia are examples of a cholinergic deficit state
Dopamine Associated with the reward center of the brain Both older and newer antipsychotics involve blockade of DA transmission, since psychosis is associated with INCREASED dopamine activity Methylphenidate and Amphetamine enhance the release of dopamine from the ventral tegmental area, since ADHD is associated with DECREASED dopamine activity
Serotonin Modulation of its receptors and the reuptake site have been beneficial in treating depression, anxiety, OCD, and schizophrenia Plays important roles in sleep, mood, appetite, perception, and hormone secretion, as well as neurodevelopment
Norepinephrine Modulates sleep cycles, appetite, mood, and cognition by targeting the thalamus, limbic structures and cortex
Diagnoses
ADHD Involves inattention and distraction, with or without hyperactivity-impulsivity 6 or more symptoms for at least 6 months, occurring in more than 1 setting, and prior to age 12 Symptoms do not occur exclusively during a psychotic disorder, and are not better explained by another Dx Studies indicate both DA and NE deficiencies in these patients Family and twin studies strongly indicate the inheritability of the disorder
Depressive Disorders Disruptive Mood Dysregulation Disorder Major Depressive Disorder Persistent Depressive Disorder (Dysthymia) Premenstrual Dysphoric Disorder Substance/Medication-Induced Depressive D/O Depressive D/O Due to Another Medical Condition Other Specified Depressive Disorder Unspecified Depressive Disorder
Major Depressive Disorder SSIGECAPS Suicidal thoughts Sad or depressed mood Interest and pleasure markedly decreased Guilt, worthlessness Energy markedly decreased, fatigue Concentration/thinking difficulties Appetite decreased OR increased; or wt loss or gain Psychomotor changes (agitation or retardation) Sleep (insomnia or hypersomnia)
Depressive Disorders Childhood Clinical Presentation Irritability, low frustration tolerance, temper tantrums, somatic complaints, social withdrawal, acting out, school refusal, FTT Adolescent Clinical Presentation Anger, academic problems, behavioral changes, recklessness, social withdrawal, giving away valuables, frequent school absences, more melancholic symptoms, more suicide attempts and delusional symptoms than seen in children
Disruptive Mood Dysregulation Disorder Was created and added to the DSM-V to better encapsulate a subset of children with persistent, chronic, consistently irritable mood WITHOUT a previously diagnosed manic/hypomanic episode Was done following an upswing in the numbers of pediatric bipolar disorder diagnoses with the DSM-IV TR and earlier
Bipolar Disorders Bipolar I Disorder Bipolar II Disorder Cyclothymic Disorder Substance/Medication-Induced Bipolar and Related Disorder Bipolar and Related Disorder Due to Another Medical Condition Other Specified Bipolar and Related Disorder Unspecified Bipolar and Related Disorder
Mania and Hypomania DIGFAST Distractibility Increased goal-directed activity or psychomotor agitation Grandiosity Flight of ideas, racing thoughts Activities with high potential for negative consequences Sleep Talkativeness
Anxiety Disorders Most common of all childhood psychiatric diagnoses 15-20% of children will develop anxiety if their parents have it (anxious parents tend to beget anxious children) Preschool Separation Anxiety Disorder School Age Specific Phobia (fearful of dark, monsters, insects) GAD Selective Mutism OCD Adolescence Social Anxiety Disorder Panic Disorder
Behavioral Disorders Oppositional Defiant Disorder Conduct Disorder Other Specified Disruptive, Impulse-Control and Conduct Disorder Unspecified Disruptive, Impulse-Control, and Conduct Disorder
Schizophrenia Spectrum and Other Psychotic Disorders Delusional Disorder Brief Psychotic Disorder Schizophreniform Disorder Schizophrenia Schizoaffective Disorder Substance/Medication-Induced Psychotic D/O Psychotic Disorder Due to Another Medical Condition Other Specified Schizophrenia Spectrum and Other Psychotic D/O Unspecified Schizophrenia Spectrum and Other Psychotic Disorder
Psychotic Disorders Delusions are less complex in children versus adults Hallucinations are less elaborate in children Most children who report hallucinations do NOT have schizophrenia Childhood onset cases resemble poor-outcome adult cases Gradual onset and prominent negative symptoms These children are more likely to have experienced nonspecific emotional-behavioral disturbances and psychopathology, intellectual and language alterations, and subtle motor delays
Autism Spectrum Disorder With or without accompanying intellectual impairment With or without accompanying language impairment 25% begin talking after diagnosis; 75% remain severely impaired Social Interaction Social Communication Behaviors Varying degrees of severity Level 1 Level 2 Level 3 Adolescents and adults are prone to anxiety and depression
Anxiety versus Depression GAD and worry are common features of depressive, bipolar and psychotic disorders, and should NOT be separately diagnosed if excessive worry occurs during the course of these conditions
MDD versus ADHD Both can have distractibility and low frustration tolerance, but if criteria are met for both, then both diagnoses should be made Caution should be taken not to overdiagnose a MDE in children with ADHD whose mood disturbance is irritability versus sadness or loss of interest
ADHD versus Bipolar D/O ADHD is common in preadolescents, whereas bipolar disorder is rare in this age group Children with ADHD may exhibit significant mood changes within the same day, which is different from mood lability associated with mania, which must last 4 days or longer for the bipolar disorder diagnosis
DMDD versus Bipolar D/O Should not be diagnosed for the first time younger than age 6 yrs or older than age 18 years Consistent pattern of irritable mood, not episodic mood changes like with Bipolar Disorder DMDD cannot be diagnosed in a child who has ever experienced a manic/hypomanic episode lasting > 1 day or a full manic/hypomanic episode DMDD is not associated with grandiosity and expansive or elevated mood
DMDD versus ODD DMDD children have mood symptoms not typically seen in children with ODD While most children with DMDD have symptoms consistent with ODD, the reverse is not true In children with diagnostic criteria for both disorders, only the diagnosis for DMDD should be made
Comorbidities ADHD ODD, CD, DMDD, SUD, specific learning disorder Depressive Disorders SUD, Panic D/O, OCD, AN, BN, Borderline PD Anxiety Disorders Other Anxiety D/O, MDD, SUD Bipolar Disorder Anxiety D/O, ADHD, Disruptive Impulse Control D/O, CD, SUD Psychotic Disorders SUD (++nicotine), Anxiety D/O (++OCD and Panic D/O)
Sleep plays a major role! Poor sleep negatively impacts mood, concentration, frustration tolerance, cognitive abilities/academic performance, appetite, level of motivation and psychomotor movement Poor sleep can mimic and mask various psychiatric diagnoses GOOD SLEEP HYGIENE IS ESSENTIAL
Use of Psychotropic Medication in Children
START LOW AND GO SLOW!
Effects of Medication Pharmacokinetics Describes what the body does to a drug ADME (absorption, distribution, metabolism, excretion) Pharmacodynamics Describes what the drug does to the body Involves the short and long-term effects of drugs on neuronal function and structure
ADHD Medications Stimulants Gold Standard for treatment of ADHD Non-Stimulants Use when patient cannot tolerate a stimulant
Stimulants Methylphenidate Dexedrine Ritalin Focalin Concerta Daytrana patch Amphetamines Adderall Vyvanse Amphetamine salts
Methylphenidate VS Amphetamines Both enhance the release of DA Amphetamines also inhibit the reuptake of DA Typical side effects of stimulants: Appetite suppression weight loss Insomnia Mild headache
Non-Stimulant Meds Strattera Selectively blocks reuptake of NE NE reuptake inactivates DA, therefore can increase DA transmission in the frontal cortex NOT limbic areas 0.5-1.2mg/kg/day in children up to 70kg 40-100mg/day in adults Typical side effects Sedation and fatigue Decreased appetite Can also autonomic effects of increased NE (BP,HR)
Non-Stimulant Meds Blood Pressure Medications Work by acting on post-synaptic alpha-2 receptors in the prefrontal cortex Typical side effects are dry mouth, sedation, dizziness, rebound effects if not tapered slowly Clonidine 0.1-0.4mg/day in divided doses Tenex 1-2mg/day Intuniv (long-acting formulation) 1-4mg/day
Antipsychotics Typically used for mood stabilization and anger in children, but also for psychosis, Tic Disorders and irritability associated with Autism Spectrum Disorders Risperdal Abilify Zyprexa Seroquel Haldol Geodon
Abilify DA partial agonist Reduces DA output when levels are high improving positive symptoms of schizophrenia Increases DA output when levels are low improving cognitive, negative and mood symptoms Blockade of serotonin receptors improve cognitive and affective symptoms
Abilify FDA-approved for schizophrenia ages 13 >, acute and mixed mania ages 10>, autism-related irritability ages 6-17 Typical side effects: Dizziness, insomnia, akathisia, activation, NV 15-30mg/day for schizophrenia and mania 2-10mg/day when used with SSRI or SNRI Remember, LOW AND SLOW with children
Risperdal Second-generation, atypical antispychotic Most commonly used antipsychotic in children FDA-approved for schizophrenia (ages 13>), manic and mixed-manic states (ages 10>), and irritability associated with ASD in children (ages 5-16) Blocks DA disinhibition of prolactin hyperprolactinemia breast enlargement and galactorrhea At high doses, functions like Haloperidol
Risperdal Blocks alpha 1 receptors dizziness, sedation, hypotension Blocks DA2 in striatum motor side effects Blocks DA2 receptors in pituitary gland elevations in prolactin Usual dose range for children is 0.5-2mg/day Like all atypical antipsychotics, can result in the development of Metabolic Syndrome
Metabolic Syndrome A group of risk factors associated with atypical antipsychotics that increase a patient s chances of heart disease, DM, stroke, etc Need at least 3 risk factors for the diagnosis: Large waistline Increased triglycerides in blood Decreased HDL (the good cholesterol) Increased blood pressure Increased fasting blood glucose
Antidepressants SSRI s are gold standard, and are the most researched in children Prozac, Celexa, Lexapro, Paxil, Zoloft 2 have been FDA-approved Prozac Lexapro Wellbutrin, Remeron, Effexor, Pristiq
FDA-approval for acute treatment of Bipolar 1 Disorder, Mixed or Manic Episode Abilify (10 years and older) Risperdal (10 years and older) Seroquel (10 years and older) Lithium (12 years and older) Zyprexa (13 years and older)
Mood Stabilizers Lithium Gold Standard for Bipolar Disorder Anti-Convulsant Medications Depakote Lamictal Trileptal Anti-Psychotic Medications Abilify Risperdal Zyprexa
FDA-Indications Zoloft OCD, 6 years and older Prozac OCD, 7 years and older MDD, ages 8 and older Luvox OCD, 7 years and older; both formulations SAD; CR formulation Clomipramine OCD, 10 years and older Lexapro MDD, ages 12 years and older
Anxiolytics SSRIs medication class of choice in children Prozac Zoloft Lexapro Luvox Clomipramine Buspar Benzodiazepines Treatment of last resort
Clinical Research and Evidence-Based Treatment
TADS Study Treatment for Adolescents with Depression Study Study involving the improvement/response rate of CBT with and without fluoxetine Revealed that both CBT + fluoxetine demonstrated the best treatment outcome By week 18 of the trial, CBT alone and fluoxetine alone had comparable response rates By week 36, all three parameters had similar response rates
TORDIA Study Treatment of SSRI-Resistant Depression in Adolescents CBT + meds was superior than meds alone No overall difference between SSRI and Venlafaxine
CAMS Study Child/Adolescent Anxiety Multimodal Treatment Study Similar in structure to TADS Indicated that combined treatment (CBT + sertraline) was superior to both meds alone and CBT alone
POTS Study The Pediatric OCD Treatment Study Combined treatment (CBT + meds) superior to either meds alone or CBT alone Weeks 4-8 indicated sertraline was more effective than CBT By week 12, CBT was slightly more effective than sertaline alone
How can we help? Rating scales Knowing what to look for MSE pertinent positives Rapport with patient to establish trust Your endorsement of medication-- if needed
References Martin A, Volkmar FR: Lewis Child and Adolescent Psychiatry, A Comprehensive Textbook. Philadelphia: Lippincott, Williams and Wilkins; 2007 American Physician Institute for Advanced Professional Studies: Beat The Boards! 2012 Child and Adolescent Psychiatry Part 1 Exam Prep Course. Schatzberg AF, Nemeroff CB: Essentials of Clinical Psychopharmacology. Arlington: American Psychiatric Publishing; 2013 Stahl SM: Stahl s Essential Psychopharmacology Prescriber s Guide. New York: Cambridge University Press; 2014 DSM-V