Transcript Unit L: Aggression in Youth

Assessment/Treatment of
Aggression in Youth
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Disclosures
The following planners and speaker of this
CME activity has no relevant financial
relationships with commercial interests to
disclose:
•
•
•
•
•
•
•
Lawrence Amsel, M.D.
Diane Bloomfield, M.D.
Cathryn Galanter, M.D.
Harlan Gephart, M.D.
Peter Jensen, M.D.
Robert Kowatch, M.D.
Rachel Lynch, M.D.
•
•
•
•
•
•
•
Suzanne Reiss, M.D.
Mark Riddle, M.D.
Jyoti Bhagia, M.D.
Ruth Stein, M.D.
Mark Wolraich, M.D.
Rachel Zuckerbrot, M.D.
Elena Man, M.D.
Copyright © The REACH Institute. All rights reserved.
Disclosures
The following planner and speaker of this
CME activity has financial relationships with
commercial interests to disclose:
Laurence Greenhill, M.D.
– Bio BDX – Scientific Advisory Board
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Learning Objectives
To safely & effectively learn the role & use of medications
for severe pediatric aggression, participants will learn to:
1) Differentiate among pediatric problems that present with
aggression, including depression, ADHD, bipolar disorder,
psychosis, and conduct disorder.
2) Create and implement an effective treatment plan by
mobilizing existing resources, i.e., delegating tasks to
family members and other professional caregivers.
3) Effectively utilize psychopharmacologic approaches for
clinical aggression, including:
a) Selecting medications for individual patients
b) Initiating and tapering dosages
c) Monitoring improvements
d) Identifying and minimizing medication side effects
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Agenda
• Learn the various types of aggression presenting
in clinical settings
• Observe and discuss a “typical case” – Todd and
his parent(s)
• Learn about the “T-MAY” guideline and toolkit,
and its use in assessing, treatment planning, and
managing severe aggression
• Discuss role and the safe/effective use of atypical
neuroleptics in children and adolescents with
severe aggression
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Case Presentation:
Your Patient Todd
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Mental Health Card
For children under 11 y/o, meet with parent and child together to discuss chief concern.
Then meet alone with child for at least five minutes.
For adolescents, consider meeting with adolescent first.
CHIEF CONCERN
If not specific, consider starting with school and social history
SYMPTOM-SPECIFIC HISTORY
DESCRIPTION: (what it is…get concrete examples, including)
Time Frame: Initial event? Persistent/intermittent? Duration? Cyclical? Prolonged hiatus?
When: Global? Triggered? Persistent/intermittent? Cyclical? Prolonged hiatus?
Setting: School? Home? Alone? With others? Who?
Intensity?
What makes it better? What makes it worse?
RESPONSE:
How do you deal with it?
Is there anything that YOU do that makes it better?
Adaptive skills?
EtOH? Self-medicating?
Is there anything that YOU do that makes it worse?
IMPAIRMENT:
Tell me how bad it gets/got…describe it to me (time, place, situation)
What’s the worst it ever got?
Depression?
Suicidal thoughts?
Aggression?
What does it stop you from doing?
REVIEW OF SYSTEMS (e.g., Mood, Sleep, Appetite, Energy, Concentration, Anxiety, Aggression, etc)
BIRTH, DEVELOPMENTAL AND BEHAVIORAL HISTORY
RELEVANT MEDICAL HISTORY (include meds/otc)
SCHOOL HISTORY
Academics? Behavior? Extra services? Recent changes?
May need to get parental permission to communicate with school
SOCIAL HISTORY
Living environment
Trauma History, including witnessed domestic violence
Friends (changes, new, withdrawal)
Substance use
Functioning, strengths, interests
TARGETED FAMILY HISTORY
SAFETY--danger to self, danger to others
Is the home safe (no guns, access to Tylenol, etc)?
Safety Plan/Contract: (What is the plan if thoughts of harming self or others emerge?)
LAB VALUES/TOOLS
ASSESSMENT/DIAGNOSIS
TREATMENT OPTIONS (consider guidelines or algorithm)
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SOAP
Case Presentation:
Todd continued
• What would you do?
• Audience input
• See Todd’s scored Vanderbilt (L 1.2&
1.3) in Workbook
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NICHQ
Vanderbilt
Assessment
Scale:
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Parent
information
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NICHQ
Vanderbilt
Assessment
Scale:
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Parent
information
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Assessment of Aggression
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Impulsive-Aggressive Spectrum
Bipolar
spectrum
ADHD
spectrum
Cluster B
personality disorders
Antisocial
Borderline
Conduct
Disorder
Substance
abuse
Severe
Anxiety
Impulsivity
and
Aggression
Impulse
control
disorders
PTSD
Tourette’s
/OCD
Developmental
disorders
Autism
Spectrum
disorders
Schizophrenia
Spectrum
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Type
Clinical Description
1. Impulsive
Unprovoked, brief, rapid,
thoughtless, inability to delay
reward/recognize consequences; out
of proportion and out of the blue
2. Affective Storm/”Hot” Exaggerated response to affectively
provoked or charged (i.e. difficulty
modulating arousal), reactive. “Hot
blooded” aggression. Extended
duration (30+ minutes)
3. Anxious/hyperarousal Overstimulation, overwehelmed,
response to xs anxiety; lash out with
relief of tension
4. Cognitive/disorganized Distorted perceptions, impaired
reasoning, delusions, paranoia
5. Predatory/”Cold”
Premeditated, consciously executed,
instrumentally motivated, “cold
blooded”
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Representative
DSM Dx
ADHD
Bipolar
TBI
IED
Bipolar
PDD/ID
ADHD
Subst. abuse
MDD/Dysthymia
PTSD
PDD
OCD
Psychosis
Bipolar
Schizophrenia
TBI/FAS/Brain
damage
Sub. Abuse
CD, ASP
Aggression in Children & Adolescents:
Critical Issues
• Most common reason for psychiatric referral
• Complicates treatment/leads to poorer
outcomes
• Frequent use of atypical antipsychotics and
multiple medications
• Lack of controlled trials to inform physicians’
prescribing practices
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TREATMENT OF
Produced with support from
MALADAPTIVE
AGGRESSION
IN YOUTH
T-MAY
The Rutgers CERTs Pocket Reference Guide
For Primary Care Clinicians and Mental Health Specialists
Copyright © 2010
Center for Education and Research on Mental Health Therapeutics (CERTs), Rutgers
University, New Brunswick, NJ*
The REACH Institute (REsource for Advancing Children’s Health), New York, NY*
The University of Texas at Austin College of Pharmacy*
New York State Office of Mental Health
California Department of Mental Health
Copyright © The REACH Institute. All rights reserved.
2
Managing Aggressive Youth
Question 1: True or False?
“Your first step is to make a valid DSM
diagnosis”
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False!
T-MAY Recommendations:
1 - Conduct a thorough assessment.
–Assessment must include: Engaging the
patient and parents (emphasizing the need for
their on-going participation and work)
2 - Get a diagnosis (remember the “General
Principles”?)
–DSM diagnosis is insufficient without
understanding the child, the family, and the
context within which the child is developing
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Initial Evaluation Prior to
Pharmacologic Treatment
• Engage parents & patients at the outset: You cannot
do it w/meds alone, nor without the family!
• Assessment & Diagnostic interview with patient and
parent/guardian
–
–
–
–
–
Contact prior treating physician
Review treatment records
Contact teachers
Identify other medications being taken
Assess the child’s developmental needs: what is missing?
• Physical examination
• Appropriate laboratory studies
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Managing Aggressive Youth
Question 2: True or False ?
Response to treatment can be adequately
monitored by using clinical interview and
clinical judgment alone.
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False!
T-MAY Recommendations
• Define target symptoms & behaviors in
partnership with parents and child
• Assess target symptoms, treatment
effects and outcomes with standardized
measures
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Standardized Measures Useful For
Aggression Include:
• Vanderbilt
• Modified Overt Aggression Scale
(MOAS)
• Nisonger Child Behavior Rating Form
(N-CBRF)
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L2.9
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L3.2
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T-MAY Recommendations
Treatment Planning
• Conduct a risk assessment & if needed,
consider referral to a MH specialist or ER
• Partner with family in developing an
acceptable treatment plan
• Provide psychoeducation to help families
form reasonable expectations
• Help the family establish community &
social supports
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T-MAY Recommendations
• Psychosocial Interventions:Provide or
assist family in obtaining evidence-based
parent-and-child skills training
• Identify, assess, and address the child’s
social, educational, & family needs, and
set objectives & outcomes with the family
• Enlist & engage the child and family in
maintaining consistent psychological &
behavioral strategies
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Mean Dose Doses:
by Weight (MG/KG)
Visit
MTA Medication
CombVersus
vs. MedMgt
(22 patients excluded and 14th visit carried forward)
Dose by Weight Over 14 Months
1.30
Mean Dose By Weight (mg/kg)
1.25
1.20
1.15
1.10
1.05
1.00
0.95
0
2
4
6
8
10
Visit
Combined Treatment
Medication Management
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12
14
16
Behavioral Principles
• Involve the parent: “I can’t do it without you.
Pills alone won’t give your child the skills he/she
needs.”
• Parent training & support
• Co-opt the youth: Involve child/youth in
monitoring and controlling aggressive outbursts
• Positive approach
– Positive reinforcement
– “Catch the child being good”
– Don’t reward negative behaviors
• Consistency and follow through
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T-MAY Recommendations
Medication Treatments
• Treat the 1 Disorder (underlying condition) first,
using recognized guidelines for that disorder.
• ONLY IF severe aggression persists after
adequate psychosocial & medication treatments
for the 1 Disorder, add an AP
– If first AP fails, try another, or consider mood
stabilizer
• If possible, avoid using more than two psychiatric
medications simultaneously
• Use recommended titration schedule and deliver
adequate doses before adjusting or changing
medications
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TRAAY: Pocket Reference Guide for Clinicians in Child and Adolescent Psychiatry (2004). NYS-OMH & CACMH
Atypical Antipsychotics: Optimal Dosing/Titration
Strategies for Children and Adolescents
Atypical
Antipsychotics
Starting
Daily-Dose
Titration Dose, q3-4
day (~Min. days to
antipsychotic dose)
2.5-5 mg
Usual Daily Dose Range
in Aggression**
Usual Daily Dose Range
in Psychosis
CHILD
ADOLESCENT
CHILD
ADOLESCENT
2.5-15 mg
5-15 mg
5-15 mg
5-30 mg
Aripiprazole
2.5-5 mg
Clozapine
6.25-25 mg
1-2x starting dose
(18-30 days)
150-300 mg
200-600 mg
150-300 mg
200-600 mg* *
Olanzapine
2.5 mg for children
2.5-5 mg for
adolescents
2.5 mg
(10-15 days)
NDA
NDA
7.5-12.5 mg
12.5-20 mg
Quetiapine
12.5 mg for children
25 mg for
adolescents
25-50 mg to 150 mg
then 50-100 mg
(18-30 days)
NDA
NDA
Risperidone
0.25 mg for children
0.50 mg for
adolescents
0.5-1 mg
(10-15 days)
1.5-2 mg
2-4 mg
3-4 mg
3-6 mg
20 mg
20 mg for children
20-40 for
adolescents
(18-30 days)
NDA
NDA
NDA
NDA; (In
adults, 160-180
mg)
Ziprasidone
(7-10 days)
NDA
300-600 mg
See WkBk L1.8c
NDA = no data available.
*There is little information to guide dosing strategies for aggression. However, for aggressive children treated with risperidone, doses are about half that
of the usual antipsychotic dose.
**In treatment resistant schizophrenic adults, a serum clozapine level (of the parent compound) greater than 350mg/dl is generally required for efficacy.
Copyright © The REACH Institute. All rights reserved.
Methylphenidate in ADHD/CD:
Impulsive Aggression
Baseline
12
MPH
P < 0.001
P < 0.003
10
Aggression
(Iowa Scale*)
Placebo
8
P < 0.03
6
4
2
0
Teacher
n=
71
35
36
Parent
74
37
37
*Sum of 5 items, range 0-15.
Klein RG et al. Arch Gen Psychiatry. 1997;54:1073-1080.
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Classroom
47 24
23
Atypical Antipsychotics in
Disruptive Behavior Disorders With
Aggression: Levels of Evidence
Atypical
Antipsychotics
Short-Term
Efficacy
Risperidone
Olanzapine
Quetiapine
Ziprasidone
Clozapine
Aripiprazole
A
C
D
C
C
B*
A = >2 randomized, controlled studies; B = 1 randomized, controlled study; C = clinical
experience, eg, open studies, case reports, etc., D = no data or negative outcome.
* Studies done with aggression/irritability in autism: Based on all available RCTs thru 8/2013
Adapted from Jobson KO, Potter WZ. Psychopharmacol Bull. 1995;31:457-459.
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T-MAY Recommendations:
Ongoing Management
• Start low, go slow, taper slow
• Routinely assess for side effects and drug
interactions, including clinically relevant
metabolic studies (To be discussed in following
session).
• Provide info to children & parents re: side effects
• Use E-B strategies to prevent-reduce side effects
• Collaborate with medical, educational, &/or MH
specialists as needed
Copyright © The REACH Institute. All rights reserved.
TREATMENT OF
Produced with support from
MALADAPTIVE
AGGRESSION
IN YOUTH
T-MAY
The Rutgers CERTs Pocket Reference Guide
For Primary Care Clinicians and Mental Health Specialists
Copyright © 2010
Center for Education and Research on Mental Health Therapeutics (CERTs), Rutgers
University, New Brunswick, NJ*
The REACH Institute (REsource for Advancing Children’s Health), New York, NY*
The University of Texas at Austin College of Pharmacy*
New York State Office of Mental Health
California Department of Mental Health
Copyright © The REACH Institute. All rights reserved.
2
See WkBk
L1.9
ASSESSMENT + DIAGNOSIS
Engage patients and parents (emphasize need for their on-going participation)
Conduct a thorough initial evaluation and diagnostic work-up before initiating treatment
Define target symptoms and behaviors in partnership with parents and child
Assess target symptoms, treatment effects and outcomes with standardized measures
T-MAY
Algorithm:
Conduct a risk assessment and if needed, consider referral to mental health specialist or ER
Partner with family in developing an acceptable treatment plan
Provide psychoeducation and help families form realistic expectations about treatment
Help the family to establish community and social supports
PSYCHOSOCIAL INTERVENTIONS
Assessment &
Diagnosis
Treatment Planning,
Treatment, and
Ongoing
Management
Provide or assist the family in obtaining evidence-based parent and child skills training
Identify, assess and address the child’s social, educational and family needs, and set objectives and
outcomes with the family
Engage child and family in maintaining consistent psychological/behavioral strategies
MEDICATION TREATMENTS
Select initial medication treatment to target the underlying disorder(s); follow guidelines for primary
disorder (when available)
If severe aggression persists following adequate trials of appropriate psychosocial and medication
treatments for underlying disorder, add an AP, try a different AP, or augment with a mood stabilizer (MS)
Avoid using more than two psychotropic medications simultaneously
Use the recommended titration schedule and deliver an adequate medication trial before adjusting
medication
SIDE-EFFECT MANAGEMENT
Assess side-effects, and do clinically-relevant metabolic studies and laboratory tests based on established
guidelines and schedule
Provide accessible information to children and parents about identifying and managing side-effects
Use evidence-based strategies to prevent or reduce side-effects
Collaborate with medical, educational and/or mental health specialists if needed
MEDICATION MAINTENANCE + DISCONTINUATION
See WkBk L2.1
If response is favorable, continue treatment for six months.
Taper or discontinue medications in patients who show a remission in aggressive symptoms ≥ 6 months
Copyright ©
The
All rights
reserved.
Note:
The REACH
order of theseInstitute.
recommendations
may be tailored
to each patient’s specific condition and needs.
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INITIAL TREATMENT + MANAGEMENT PLANNING
Table Activity
1. Review Todd’s Vanderbilt scores
2. Calculate his MOAS score? (L 1.4)
3. What type of therapy would you pick?
4. Assume Todd has continuing, severe problems:
• Which atypical would you use, and at what dose?
• What rating scale would you use to track response?
SCRIBES - Write on your flipchart:
1) MOAS score
2) Therapy choice
3) Atypical choice & dose
4) Rating Scale
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Table Activity Debrief
• MOAS Scores
• Behavior management?
• Which atypical, what dose?
• What rating scale?
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Treatment Pearls
• Use rating scales for symptoms & side effects
• Engage family and youth - LEAP
• Form “Virtual Team” – Enlist the family in reading
(your lending library?) & problem-solving
• Diagnose and treat the underlying disorder,
especially ADHD/ODD
• Encourage use of behavioral strategies, new skills
• If/when all of the above aren’t enough, consider
atypical or other agents!
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Treatment Pearls II
• Start with risperidone
• Target dose 1-2 mg/day, divided doses
• Start .25 mg qhs, add 0.25 q.am in 3-4 days if
well-tolerated
• Onset of action: 7 days; full efficacy in 4-6
weeks
• Side effects: weight gain, sedation, elevated
prolactin
• At baseline: fasting glucose, lipids, BMI, girth,
dietary consultation
• Taper at 6 months
See WkBk for T-MAY Tools L1.9-3.4
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REMINDER:
Please fill out Unit L
evaluation
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Atypical Toolbox
Atypical
Antipsychotic
Start at (mg /
day)
Target Dose
(mg/day)
Risperidone
0.25-0.50
1-3
Weight/Height/BMI EPS/TD
Aripiprazole
2.5-5
5-20
Weight/Height/BMI EPS
Quetiapine
50-100
300-600
Weight/Height/BMI
Ziprasidone
20-40
80-160
Weight/Height/BMI
ECG
Olanzapine
5
5-20
Monitor
Watch Out For
Take with food, assess
cardiac risk factors
Weight/Height/BMI Choles/FAs
Copyright © The REACH Institute. All rights reserved.
See WkBk L3.6
RESOURCE SLIDE: Examples Your
Practice Library’s Behavior Management
Books
• Making the System Work for Your Child with ADHD
(Making the System Work for Your Child)
by Peter S. Jensen, with input & tips by >100 parents
(COI: royalties go to CHADD)
• Your Defiant Child: Eight Steps to Better Behavior
by Russell A. Barkley, Christine M. Benton
• 1-2-3 Magic: Effective Discipline for Children 2-12
by Thomas W. Phelan
• The Explosive Child: A New Approach for
Understanding and Parenting Easily Frustrated,
Chronically Inflexible Children
by Ross W. Greene
L1.7
Copyright © The REACH Institute. All rights reserved.
Resource Slide: Where you Can Refer
Your Parents for Additional Support
Parent Support Groups May be available:
• Child and Adolescent Bipolar Foundation: www.bpkids.org;
847-256-8525.
• Depression and Bipolar Support Alliance:
www.dbsalliance.org; 800-826-3632 (toll-free).
• Families Together in New York State: www.ftnys.org; 888326-8644 (toll-free).
• Federation of Families for Children’s Mental Health:
www.ffcmh.org; 703-684-7710.
• National Alliance for the Mentally Ill: www.nami.org; 800-950NAMI (toll-free).
• National Mental Health Association: www.nmha.org; 800784-2433 (toll-free).
• ADHD Family Support Center: www.adhd.com
• Children and Adults with ADHD: www.CHADD.org
L1.8a
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RESOURCE SLIDE:
T-MAY Resources
• Complete 38-page Toolkit: go to website to download pdf:
www.TheReachInstitute.org (see Footer– “Resources”)
• Knapp P, et al., & the T-MAY Steering Group. Treatment of
Maladaptive Aggression in Youth (T-MAY) Guidelines I. Family
Engagement, Assessment & Diagnosis, and Initial Management.
Pediatrics, 129:e1562-1576, 2012
• Scotto Rosato N, et al., & the T-MAY Steering Group. Treatment
of Maladaptive Aggression in Youth (T-MAY) Guidelines II.
Psychosocial Interventions, Medication Treatments, and Side
Effects Management. Pediatrics, 129:e1577-1586, 2012
• Pappadopulos E, et al. Treatment of Maladaptive Aggression in
Youth (T-MAY). Results from a Consensus Survey of Expertsrecommended Best Practices. J Child Adol Psychopharm,
21:505-515, 2011
L3.5
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RESOURCE SLIDE:
Risperidone in Autism:
Irritability Scale
ABC Irritability (N=101)
ABC Irritability Total...
30.0
25.0
20.0
Risperidone Mean
15.0
Placebo Mean
10.0
5.0
0.0
0
2
4
6
Week
RUPP Autism Group, NEJM, 2002
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8