Transcript Attention Deficit Hyperactivity Disorder

Child and Adolescent
Psychiatry
Howard Liu, M.D.
Psychiatry Clerkship Director
Child & Adolescent Psychiatry
UNMC
402-552-6006
[email protected]
Revised 3.15.12
Normal Development
Goals / Objectives
• Review common diagnoses in pediatric
mental health
• Recognize epidemiology of major disorders
• Recall first line treatment guidelines
What will we cover?
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ADHD
Pediatric Bipolar Disorder
Anxiety Disorders
Autism
Eating disorders
Substance abuse
Fred Rogers
• “Play is often talked
about as if it were a
relief from serious
learning. But for
children play is serious
learning. Play is really
the work of
childhood.”
Child Psychiatry Interview Pearls
• Manage the room
• Ask intimate questions privately
• Be able to “surf” from shallow to deep
• Start with social history
• Safety is #1 priority
ADHD
Pop Quiz: ADHD
According to the largest study of ADHD to
date (the MTA trial), which was the most
effective treatment for ADHD in kids after 1
year?
A. Stimulant medication
B. Behavioral therapy
C. School intervention
D. Stimulant + Behavioral therapy
E. Low sugar diet
Elementary School child with ADHD
Epidemiology of ADHD in Children
• Prevalence is ~ 9.5% of children,
• 2/3 treated
• Males > Female by 4:1
• Life course
– Hyperactivity , Inattention persists
• High comorbidity (2/3)
– ODD, learning disorder, smoking, etc.
CDC National Survey Children’s Health 2007-2008 – 70,000 parents
Practice Parameter for the Assessment & Treatment of Children and Adolescents
with Attention-Deficit/Hyperactivity Disorder. JAACAP 2007;46(7): 894-921
Diagnostic Criteria for ADHD
(DSM-IV)
• Must occur before age 7 years
• Present for at least 6 months
• Causes impairment in at least 2 settings
• Meets 6 of 9 symptoms of inattention
AND/OR
• 6 of 9 symptoms of hyperactivity/impulsivity
Diagnosis: Inattentive Subtype
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Careless mistakes in schoolwork
Poor attention in tasks or play
Doesn’t listen when spoken to directly
Fails to finish things (not oppositional or unable)
Difficulty organizing
Avoids/dislikes tasks requiring focusing
Loses necessary items
Distracted by extraneous stimuli
Forgetful in daily activities
Diagnosis: Hyperactive-Impulsive
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Fidgets with hands/feet or squirms in seat
Often leaves seat when inappropriate
Runs about or climbs excessively when inappropriate
Difficulty playing quietly
Often “on the go” or acts as if “driven by a motor”
Often talks excessively
Blurts answers before question completed
Difficulty awaiting turn
Often interrupts or intrudes on others
Treatments
• Stimulant medications – 1st line (MTA)
• Alternative non-stimulant medications
• Psychoeducation
• Community support
• Behavioral interventions
• School interventions
Stimulant Medications: Efficacy
• One of the most robust treatments in psychiatry
• 70% of children with ADHD will respond to any
one of the stimulants, all generally equal
efficacy
• An additional 20% will respond to the next one
attempted
• If the 1st and 2nd choices fail, check for wrong
diagnosis and/or comorbidity
Medical Issues
• Growth: Faraone meta-analysis:
– after 2-3 years on stimulants, kids were 1-2.5 cm shorter
– Growth rate increases when stimulants stopped
• Cardiac Risk
– AHA: 1999 guidelines – no routine EKG
– AHA: 2008 guidelines – ‘‘...it is reasonable for a physician to
consider obtaining an ECG as part of the evaluation of
children being considered for stimulant drug therapy, but this
should be at the physician’s judgment, and it is not
mandatory to obtain one”
Bipolar disorder
Pop Quiz: Bipolar
A 14 year old girl is being treated for pediatric
bipolar disorder, when she develops breast
tenderness and galactorrhea. Which
medication is she most likely taking?
A.Carbamazepine
B.Risperidone
C.Lithium
D.Valproic Acid
E.Topiramate
Diagnosis
• Mania:
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Mood + 3 or 4 symptoms
D - Distractibility
I – Indiscretion (pleasurable activities)
G – Grandiosity
F – Flight of Ideas
A – Activity increases
S – Sleep deficit
T – Talkativeness (pressured)
• Developmental symptoms
Faust, DS et al. Diagnosis and Management of Childhood BPD in the Primary Care Setting. Clinical Pediatrics
2006;Vol. 45(9): 801-808.
FDA-Indicated Medications for PBD
• Approved down to age 12 years for acute mania and
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maintenance therapy
– Lithium: grandfathered in based on adult literature
Approved only for acute treatment of manic/mixed episodes in
children aged 10-17 years
– Risperidone: 2007
– Aripiprazole: 2008
– Quetiapine: 2008
Approval in process
– Olanzapine
– Ziprasidone
Anxiety Disorders
9 / 11 Attack
Common Anxiety Disorders
• Separation anxiety
– Anxiety about separation from loved one
– School refusal, somatic complaints
– Risk factor panic disorder, agoraphobia
• PTSD
– Preschool alternative criteria: less play
• OCD
• Panic disorder
• Generalized anxiety disorder
• Specific phobia / Social phobia
Treatment
• CBT – 1st line, often in combo with medication
– Exposure & response prevention
• Medications
– OCD: SSRI (POTS), clomipramine, augmentation
– PTSD: SSRI, SGA (hyperarousal)
– Panic / Separation anxiety / Social phobia / GAD :
• SSRI (RUPP study fluvoxamine)
• Pearl: for anxiety, always use CBT + SSRI
PERVASIVE DEVELOPMENTAL
DISORDERS
Asperger’s Video
Pop Quiz: Autistic savants
Kim Peek was the mega savant that inspired
“Rain Man.” What is his prodigious skill?
A. Near perfect recall of 12,000 books
B. Ability to hear any song and reproduce it
on the piano
C. Ability to sculpt a perfect replica of any
animal he sees
D. Recitation of Pi from memory to 22,514
digits
Pervasive Developmental Disorders
• Definition:
– Group of psychiatric conditions in which expected social skills,
language development, and behavioral repertoire either don’t
develop or are lost in early childhood
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Early in life (by age 2)
Cause persistent dysfunction
Often associated with mental retardation (50%)
Spectrum of severity
Diagnosis
• History – early development, age of onset, family and
medical history
– AAP 2007: screen all kids 18 months, age 2
• Developmental & psychological assessment
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Intelligence, learning
Communication – language, nonverbal
Adaptive behavior – generalize skills to real world
OT / PT as needed
• Psychiatric exam
– Social relatedness, behavior, language, play skills
• Medical – genetics, seizures, hearing, etc.
Epidemiology
• Autistic Disorder
– Prevalence: 2.5 to 72 per 10,000 children
– Distributed equally among all socioeconomic levels
– Male to female ratio 3:1
– Genetic cause
– Debunked thimerosol, MMR vaccine theory
– Lifetime cost of care: $3 million
• Asperger’s disorder
– Prevalence: 4.3 per 10,000
– Male to female ratio 10:1
Autistic disorder
• 6 items from 3 categories
– Category 1: Social impairment
• Nonverbal impairment (eye contact ,facial expression,
posture, etc.)
• Peer relationships (not same age kids, often younger)
• Lack of sharing interests with others
• Lack of social or emotional reciprocity
– Category 2: Communication – language, speech
– Category 3: Restricted patterns of behavior,
interest, activities
• intense interest 1 area, rigid, flapping hands, parts
Asperger’s disorder – like “WALL-E”
• Social impairment – but they want friends
• Repetitive patterns of behavior
– Star Wars, machines, World of Warcraft, etc.
• NO language delay
– often advanced speech – “Little Professor”
• “High functioning autism”
– normal to high normal intelligence
Other PDD Disorders
• Rett’s
– Girls > boys (boys often die in infancy)
– Normal prenatal & perinatal
– Head growth decelerates, 5-48 mos.,
usually before 1 year old
– Loss of abilities, MR, language
– Motor deterioration, sudden death
• Childhood Disintegrative
– Normal development x 2 years
– Loss of prior skills – language, social skills, bowel/bladder,
play, motor skills
Autistic Disorder
Treatment
• No cure for autistic disorder
• Primary goals
– promote social and communication skills
– reduce maladaptive behaviors
– alleviate family stress
• Best interventions are educational and behavioral
– Applied Behavior Analysis (ABA), Early Intervention
– Evidence for efficacy in increasing IQ (Early Start Denver
Model)
• Pharmacotherapy to target specific symptoms:
– Antipsychotics, stimulants, SSRI’s
– “Start low, go slow”
Eating Disorders
Pop Quiz: Eating Disorders
What is the % body weight below which one
qualifies for anorexia nervosa?
A. 90%
B. 85%
C. 80%
D. 75%
E. 70%
Anorexia Nervosa
• DSM
– Body weight < 85% expected or failure to gain expected
weight
– Intense fear of gaining weight
– Denial, distorted body image
– Amenorrhea (3 consecutive cycles lost)
• Clinical
– Often high achievers, athletes
– Very rigid
Bulimia nervosa
• DSM
– Recurrent binges (lack of control, greater portion)
– Recurrent purging (vomiting, laxatives, fasting,
excessive exercise)
– Binging and purging occur at least twice weekly for
3 months
– Self image is unduly influenced by weight/shape
– Does not occur during episodes of anorexia nervosa
Treatment
• Anorexia
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Highest mortality rate of all mental illness
5-10% die within 10 years, 18-20% within 20 years
Recovery: 1/4 get better, 1/4 worse, 1/2 partial recovery
Team approach:
• Therapy, pediatrician, residential treatment
• Lack of resources
• Bulimia
– Best evidence for CBT
– SSRI is helpful
Substance Abuse
Teen drinking
Pop Quiz: Substance abuse
Which teen movie stars a celebrity who has
NOT been convicted of a DUI?
A. Transformers
B. Mean Girls
C. Braveheart
D. House of Wax
E. Superbad
Epidemiology
• Monitoring the Future 2008 Survey
- 46,000 8th, 10th, 12th graders
– NIDA, U of Michigan
– Any drug use: lifetime 20% 8th grade, 47% seniors
– Declining: Cigarettes, stimulants, alcohol
– Steady: Marijuana
– Increasing: prescription pills
• Almost 10% of seniors had used vicodin in the past year!
Teen Substance Abuse
• Abuse: 1 or more over 12 months
– Fail to meet expectations at work, school, or home
– Using when it’s dangerous (driving)
– Legal problems that are substance related
– Keep using despite repetitive problems
– Occurs over 12 month period
Abuse vs. Dependence
• Abuse: 1 or more over 12 months
– Fail to meet expectations at work, school, or home
– Using when it’s dangerous (driving)
– Legal problems that are substance related
– Keep using despite repetitive problems
– Occurs over 12 month period
Abuse vs. Dependence
• Dependence: 3 or more over 12 months
– Tolerance – need to use more
– Withdrawal
– Use larger amount than intended
– Desire to cut down
– Lots of time spent in obtaining substance
– Important social, work, or play activities are given
up
– Used despite knowledge of having a problem
Treatment
• Programs
• Individual therapy
– Motivational interviewing
• Medications
– Smoking: Wellbutrin, Chantix
– Alcohol: Disulfiram, acamprosate
– Opiates: suboxone, methadone
It is never too late to have a happy
childhood
Tom Robbins