Transcript Psychotropic Medications in Children and Adolescents

Mental Health in the
Schools: Collaboration,
Communication and
Medications
Elizabeth Reeve MD
HealthPartners
Email
 [email protected]
Today’s Content
 Collaboration
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Stakeholders
Goals
Problems
 Communication
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Teachers, parents, psychologists, others
 Diagnosis
 Medications in the classroom
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Side effects, monitoring
Collaboration
 One other thing- I was not comfortable
passing out the ADHD forms you wanted
filled out by teachers, coaches... I do not
want him to be negativiely stereotyped
any more than he already is. It doesn't
help his self esteem. I'll bring in 4 of
them, however, filled out by myself, my
husband, and our daughters who've
lived on their own now for yrs but know
the situation quite well.
Collaboration
 Stakeholders and Goals
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The individual student versus the school
Whose best interest is being considered
“The rights” of the student
 IEP
and 504s
Collaboration
 Parent problems
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Fears of being “labeled”
Unrealistic expectations for teachers and
MDs
 Physician problems
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Lack of time to communicate with teachers
 Teacher
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schedule versus MD schedule
Lack of reimbursement
Collaboration
 Teacher/School problems
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Lack of contact with the physician
Pull between the needs of the school and
the needs of the individual student
Medical goals may not be the same as the
academic goals
 Symptom
treatment versus educational goals
Communication
 Use of rating scales
 Release of information
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How much should the school know
Fears from the family that the school will
know too much
 The need for school data in order to
confirm diagnostic issues
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Social data, attention, learning
Diagnosis
 School: ASD
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MD thinks they have ADHD and an
expressive language delay
 Physician: Anxiety and LD
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School thinks they are oppositional and
should be in an EBD room
 Parental confusion?
 Does the diagnosis matter?
Medications
 Basic principles
 Stimulants, SSRI’s, mood stabilizers,
antipsychotics
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What are the uses
Side effects that impact the school setting
and/or learning
Basic Principles
 There is no match between diagnosis and
specific pharmacologic treatment

Example: ADHD maybe treated with stimulants,
nonstimulants, antidepressants
 Drug choice is made by the presence of a
symptom, not by virtue of a diagnosis
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For example: antipsychotics may be used for:
augmentation in the treatment of anxiety and
depression, psychosis, mood instability,
aggression, explosive behavior or autism
So………
 Identify the target
symptom
 Then choose the
medication
The Seven Deadly Sins
 Don’t treat
 Failure to set a target symptom
 Start meds but don’t adjust
 Start meds but adjust too much
 Setting the wrong expectations
 Failure to monitor
 Continuing medications with no efficacy
Medication Comparison:
Methylphenidate Products
Medication
Frequency
Duration
Ritalin
tid
2-4 hours
Focalin
bid
2-5 hours
Ritalin SR
qd or bid
5 hours
Ritalin LA
qd
6-8 hours
Metadate CD
qd
8 hours
Focalin XR
qd
10 hours
Concerta
qd
12 hours
Daytrana
qd
14 hours
Medication Comparisons:
Dexedrine Products
Medication
Frequency
Duration
Dexedrine
bid or tid
5 hours
Adderall
bid or tid
5 hours
Dex SR
qd
6-9 hours
Adderall XR
qd
9-10 hours
Lisdexamfetamine qd
12 hours
Ritalin® LA: Extended-release
Delivery via SODAS™ Technology
SODAS™ is a trademark of Elan Corporation, Plc
Metadate CD
Adderall XR
Daytrana
Common Stimulant Side
Effects
 Appetite loss (expected)
 Insomnia
 Tics
 Headache
 Nausea
 Rebound irritability
 Growth suppression
Common Issues With
Stimulants
 Most children adolescents are under dosed
 OK to increase dose rapidly
 There is no efficacy difference between
various stimulants
Other Medications for
Attention, Hyperactivity
 Atomoxetine (Strattera)
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Non-stimulant
Needs to be given everyday
Takes weeks to work
Can be refilled over the phone
May be better for persons with anxiety
Primary side effects
 Sedation,
nausea and vomiting, weight loss,
Other Medications for
Attention, Hyperactivity
 Clonidine or Tenex
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Need to be given everyday, multiple doses each
day
Take weeks to work
Main side effect is sedation
 Wellbutrin
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Given every day
Risk of seizures
Needs to be given 24/7
Takes weeks to work
Stimulant Issues in School
 Students will not eat lunch
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Appetite suppression is expected
 What time do the meds wear off?
 They don’t work if you don’t take them
 Bothersome tics
 Are there other reasons for attention
problems?
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Learning issues, anxiety
Selective Serotonin Reuptake
Inhibitors
 Fluoxetine (Prozac)
 Fluvoxamine (Luvox)
 Paroxetine (Paxil)
 Sertraline (Zoloft)
 Citalopram (Celexa)
 Escitalopram (Lexapro)
SSRI’s
 There is no efficacy difference between
any of the SSRI’s

All are potentially equally beneficial for
depression and anxiety
 Individuals
have different responses but there
are not group efficacy differences
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The anxiety disorders that can be treated
with an SSRI include GAD, Separation
Anxiety, Social Anxiety Disorder, OCD,
Panic Disorder, PTSD. Elective Mutism
SSRI’s
 All SSRI’s have the same general
potential side effects
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Restlessness, akathesia
Insomnia or fatigue
Appetite changes, increased or decreased
GI upset
Headaches
Sexual dysfunction
SSRI’s
 Serotonin syndrome
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Can happen with any SSRI, as well as other me
serotinergic effect such as venlafaxine,
clomipramine, fenfluramine
Rapid onset
Symptoms related to flood of extracellular 5HT
May be frightening for the patient
 trembling,
shivering, fever, chills, clonus,
hyperreflexia, may seem ataxic
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Treat with support and 5HT blockers
 cyproheptadine
and chlorpromazine
SSRI’s
 SSRI withdrawal
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Paroxetine probably the worst
Does not happen with fluoxetine
 Characterized by flu-like syndrome
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Fever, shaking, fatigue, sweating, nausea,
diarrhea
Usually starts within 24-36 hours and resolves
within 2-3 days, although may last longer
 Treat by restarting medication and slowing
down the taper
Choosing an SSRI
 Knowledge of the parent about a
particular drug
 Side effect differences
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Weight gain, sedation, activation
 Past history
 Cost
Other Antidepressants
 Buproprion
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A great antidepressant but it does not help
anxiety
 Venlafaxine and duloxetine are both
serotonergic and noradrenergic reuptake
inhibitors. Should help for both
depression and anxiety
 Trazodone and mirtazpine are used
most often as sleep aids rather then
antidepressants
SSRI Issues in School
 Restlessness
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A common side effect and may show itself
as aggression or irritability
 Take weeks to work
 Emergence of suicidal thinking
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Fact or fiction
Assessing suicidality
 Sexual dysfunction
Mood Stabilizers
 Old
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Lithium
Depakote
Carbamazepine
 New
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Oxcarbamazepine
Gabapentin
Lamotrogine
Topiramate
Others
Mood Stabilizers
 A wide variety of uses
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Bipolar Disorder
Augmentation in depression
Explosive behavior
Mood irritability
Conduct disorder
Side Effects
 Lithium
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Weight gain
Acne
Increased thirst and
urination
May effect thyroid
and kidneys
Cognitive impact
 Depakote
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Weight gain
Polycystic ovaries
Osteoporosis
Mood Stabilizer
 Topiramate
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“Dopamax”
Sedation
 Lamotrogine
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Rash
Antipsychotics: Old or New?
 The Old
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Haldoperidol
Thioridazine
Thiothixene
Proclorpromazine
Perphenazine
Fluphenazine
 The New
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Clozapine
Risperidone
 Paliperidone
Olanzapine
Ziprasidone
Aripiprazole
Quetiapine
Differences Between Old and
New
 Old
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Less expensive
Weight gain
Elevated prolactin
Tardive dyskinesia
Few trials with kids
and adolescents
 New
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More expensive
Some may have less
weight gain
Some may have
less prolactin
change
May cause less
tardive
More research in
kids and adolescents
Metabolic Syndrome
 All antipsychotics may cause an
increase in cholesterol, triglycerides, and
risk for diabetes
 Draw baseline labs and record weight

HgbA1c, fasting lipid panel
 Check labs at least yearly, perhaps
sooner if significant weight gain
Weight Gain
 Weight gain contributes to low self
esteem and medication non compliance
 Medical consequences of excessive
weight

HTN, DM, sleep apnea, PCOS, joint and
back pain
Weight Gain for Each Drug
 The literature suggests that the relative
risks for diabetes, weight gain, and
elevated lipids is as follows:
Clozapine = Olanzapine > Risperidone =
Quetiapine > Aripiprazole = Ziprasidone
 The additional use of Depakote or lithium
may increase the risks
Issues At School With
Antipsychotics
 Weight gain
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Self esteem, lethargy, hunger
Enlist the help of school nurse
 NO
SCHOOL LUNCH
 Restlessness
 Sleepiness
 Other movement issues
School Lunch
 The elementary school lunches average
821 calories per lunch with 30 percent
fat
 The biggest problem, is that students
can choose food items from the a la
carte lines that are not as balanced and
nutritious as the actual school meal.
“The dietary guidelines for the a la carte
line hasn’t been updated since the
1970s,”
School Lunch
 Updated recommendations
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500 calories for breakfast and 650 for
lunch for kindergarten through fifth grade
550 for breakfast and 700 for lunch for kids
in sixth to eighth grade
600 for breakfast and 850 for lunch for high
school students
Questions????