Transcript Child Psychiatry: Clinical Challenges Mick Storck, MD [email protected] (206)469-6282 University of Washington “you suffer captivity…but you will have contributed a word to the poem…” Inferno 1, 32

Child Psychiatry: Clinical Challenges
Mick Storck, MD
[email protected]
(206)469-6282
University of Washington
“you suffer captivity…but you will have
contributed a word to the poem…”
Inferno 1, 32 Jorge Luis Borges
Objectives
This slide set is “over-inclusive”…this is a big topic…and has, historically,
been allotted two hours in the clerkship. My goal is that these slides are
semi-academic and semi-intriguing… and that you stay forever young.
Mick
Lecture goals:
 Discuss problem/risk prevalence
 Discuss explanatory and intervention challenges in child mental health
 Review research status of interventions
 …Augmenting the Andreason/Black textbook chapter on Child
Psychiatry
Peds Psych …OLD Diagnostic Categories (DSM-IV)
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Autistic Spectrum Disorders
– Autism, Asperger’s Disorder, Pervasive Developmental Disorder
Learning Disorders
– Reading Disorder, Mathematics Disorder, Disorder of Written Expression
Disruptive Behavior and Attentional Disorders
– ADHD
– Oppositional Defiant Disorder, Conduct disorder
Mood and Anxiety Disorders
– Major depression, Dysthymic Disorder, Bipolar Disorder
– Post Traumatic Stress Disorder, Obsessive Compulsive Disorder
– Generalized Anxiety Disorder, Panic Disorder, Social Anxiety, Specific Phobias
Somatoform Disorders
– Conversion Disorder, Pain Disorder, Body Dysmorphic Disorder, Somatoform Disorder
Eating disorders
– Anorexia Nervosa, Bulimia Nervosa, Eating Disorder Not Otherwise Specified
Thought Disorders
– Schizophrenia, Schizophreniform Disorder, Psychotic Disorder
Substance Use Disorders
– Abuse, Dependence, Intoxication, Withdrawal
Peds Psych NEW Diagnostic Categories (DSM-V)

Neurodevelopmental Disorders
– Intellectual Disabilities
– Autistic Spectrum Disorder
– Learning disorders
– Attention-Deficit/Hyperactivity Disorder (removed from “disruptive” disorders)

Schizophrenia Spectrum and Other Psychotic Disorders
– Schizophrenia, Brief Psychotic, Schizotypal Disorder, Psychotic Disorder due to medical conditions

Bipolar and Related disorders, Depressive disorders


Anxiety Disorders
Generalized Anxiety, Panic Disorder, Social Anxiety, Specific Phobias
Obsessive Compulsive Disorder

Trauma- and Stressor-Related Disorders (now a separate category from anxiety disorders)

Somatic Symptom and Related Disorders
–
Illness Anxiety Disorder, Conversion Disorder

Feeding and Eating Disorders
– Anorexia Nervosa, Bulimia Nervosa, Avoidant/Restrictive Food Intake

Disruptive, Impulse Control, and Conduct Disorders
–
Oppositional Defiant Disorder, Intermittent Explosive Disorder, Conduct disorder

Substance Related and Addictive Disorders

“Other Conditions That May Be a Focus of Clinical Attention”…
–
Abuse, neglect, parent child problems, partner violence, educational, housing, discord with a lodger, personal history of …, wandering associated with a
mental disorder…
Other DSMV categories…that areNot so central for kids: sleep-wake, sexual dysfunctions, dissociatiive, neurocognitive,
personality, paraphilic disorders
Symptom Clusters,
Diagnoses & Treatment
Probes
Thoughts &
Thought
Organization
Mood & Mood
Regulation
YOUTH
Acting Out
&
Social
Relating
Attention &
Impulse
Regulation
Childhood differences (from adult dx)…
Symptoms & Frequent Comorbidities
(using pediatric depression as an example)
Pediatric Depression
 Irritability: often 1º symptom
• Temper tantrums
• Mood lability
• Low frustration tolerance
 Somatic complaints
 Guilt
 Low self-esteem
 Suicidal ideation (60%)
• Suicide attempts (30%)
 Oppositional
 Social isolation
Additional Symptoms
40% - 70% with Comorbid
Diagnosis
 Anxiety disorders: 20% - 40%
 Substance misuse: 20% - 30%
 Disruptive behavior and
neruodevelopmental disorder (incl.
Conduct disorder /ADHD/learning
disorders): 10% - 80%
Natural History:
 Median episode: 1 – 8mo
 Recurrence: 20% - 60%
 Bipolar Disorder: 20% - 40%
Nonspecific Symptoms
(example of continua and overlap between sx…)
Mania
 Irritability
 Increased Energy
 Pressured Speech
 Reckless Behavior
 Grandiosity
 Distractibility
 Decreased Sleep
ADHD
 Grumpy
 Hyperactive
 Talking Fast
 Reckless Behavior
 Bragging
 Distractibility
 Restless Sleeper
Undercurrents:
Historical Trauma
(as an example of an ecologic variable… and the importance in medicine of
grasping the generational nature of patient’s narrative)

Collective and cumulative emotional wounding across generations that results from
cataclysmic events targeting a community

The trauma is held personally and collectively and is transmitted over generations

Distress generated from historical trauma is often unrecognized, misunderstood,
ignored, marginalized, or invalidated
Brave Heart (1995); Yellow Horse Brave Heart (2000)
Child Psychiatry:
Epidemiology
5 to 15 percent with clinically significant disorders
Below age 12 years: Boys outnumber girls,
Higher rates of
behavioral/learning/developmental disorders
12 to 18 years: Girls outnumber boys,
Higher rates of anxiety/affective disorders
The Youth Risk Behavior
Surveillance System (YRBS):
National probability sample of public and private schools
 Total sample size = 16,410
 School-level response rate = 81%
 Student-level response rate = 88%
 Overall response rate = 71%
 National survey every two years

Some of “what kids are up to…”
www.cdc.gov/yrbs/
(look this up for great national data on youth…)
Priority Health-Risk Behaviors
and Outcomes Monitored by YRBSS
Behaviors that contribute to the leading causes of mortality and morbidity
 Unintentional injuries and violence
 Tobacco use
 Alcohol and other drug use
 Sexual behaviors
 Unhealthy dietary behaviors
 Inadequate physical activity
 Obesity
 Asthma

Percentage of High School Students Who Watched 3
or More Hours/Day of Television,* 1999 – 2009†
100
80
Percent
60
42.8
40
38.3
38.2
37.2
35.4
32.8
2005
2007
2009
20
0
1999
2001
2003
* On an average school day.
† Decreased 1999–2009, p < 0.05.
National Youth Risk Behavior Surveys, 1999–2009
Percentage of High School Students Who Exercised
to Lose Weight or to Keep from Gaining Weight,*
†
1995
–
2009
100
Percent
80
60
51.0
51.5
1995
1997
58.4
59.9
1999
2001
57.1
60.0
60.9
61.5
2005
2007
2009
40
20
0
2003
* During the 30 days before the survey.
† Increased rapidly 1995–2001, increased less rapidly 2001-2009, p < 0.05.
National Youth Risk Behavior Surveys, 1995–2009
Percentage of High School Students Who Used an
Indoor Tanning Device,* by Sex† and Race/Ethnicity,‡ 2009
100
Percent
80
60
40
25.4
20
21.1
15.6
6.7
4.5
8.2
0
Total
Female
Male
White
Black
Hispanic
* Such as a sunlamp, sunbed, or tanning booth one or more times during the 12 months before the survey. Not
including a spray-on tan.
†F > M
‡W>H>B
National Youth Risk Behavior Survey, 2009
Percentage of High School Students Who Used a Condom During Last
Sexual Intercourse,* 1991 – 2009†
100
Percent
80
60
52.8
54.4
56.8
58.0
1993
1995
1997
1999
57.9
2001
63.0
62.8
61.5
61.1
2003
2005
2007
2009
46.2
40
20
0
1991
* Among students who had sexual intercourse with at least one person during the 3 months before the survey.
† Increased 1991–2003, no change 2003–2009, p < 0.05.
National Youth Risk Behavior Surveys, 1991–2009 www.cdc.gov/yrbs/
Juvenile delinquency
…. participation in illegal behavior by minors (juveniles)
(individuals younger than the statutory age of majority).
…Between 60-80% percent of adolescents, and pre-adolescents
engage in some form of juvenile offense.[2] These can range
from status offenses (such as underage smoking), to property
crimes and violent crimes.
…Better or worse than “conduct disorder”?
(adult delinquency?…cutting and pasting from Wikipedia)
Percentage of High School Students Who Texted or E-mailed While
Driving a Car or Other Vehicle,* by Sex† and Race/Ethnicity,§ 2011
* On at least 1 day during the 30 days before the survey.
† M > F
§ W > H > B
National Youth Risk Behavior Survey, 2011
Percentage of High School Students Who Carried a Weapon on School
Property,* 1993 – 2011†
* For example, a gun, knife, or club on at least 1 day during the 30 days before the survey.
† Decreased 1993–2003, no change 2003–2011, p < 0.05
National Youth Risk Behavior Surveys, 1993–2011
Percentage of High School Students Who Reported
Binge Drinking,* 1991 – 2009†
100
Percent
80
60
40
31.3
30.0
32.6
33.4
31.5
29.9
28.3
25.5
26.0
24.2
2005
2007
2009
20
0
1991
1993
1995
1997
1999
2001
2003
* Had five or more drinks of alcohol in a row within a couple of hours on at least 1 day during the 30 days before the
survey.
† No change 1991–1997, decreased 1997–2009, p < 0.05
National Youth Risk Behavior Surveys, 1991–2009
www.cdc.gov/yrbs/
100
Percentage of High School Students Who Drank Alcohol for the
First Time Before Age 13 Years,* 1991 – 2009†
Percent
80
60
40
32.7
32.9
32.4
31.1
32.2
29.1
27.8
25.6
23.8
2005
2007
21.1
20
0
1991
1993
1995
1997
1999
2001
2003
* Other than a few sips.
† No change 1991–1999, decreased 1999–2009, p < 0.05.
National Youth Risk Behavior Surveys, 1991–2009 www.cdc.gov/yrbs/
2009
Percentage of High School Students Who Ever Used Marijuana,*
1991 – 2009†
100
Percent
80
60
47.1
47.2
42.4
40
31.3
32.8
1991
1993
42.4
40.2
38.4
38.1
36.8
2003
2005
2007
2009
20
0
1995
1997
1999
2001
* Used marijuana one or more times during their life.
† Increased 1991–1999, decreased 1999–2009, p < 0.05.
National Youth Risk Behavior Surveys, 1991–2009 www.cdc.gov/yrbs/
Percentage of High School Students Who Ever
Took Prescription Drugs Without a Doctor’s Prescription,*
by Sex and Race/Ethnicity,† 2009
100
Percent
80
60
40
20.2
19.8
20.4
23.0
17.2
20
11.8
0
Total
Female
Male
White
Black
Hispanic
* Took prescription drugs (e.g., Oxycontin, Percocet, Vicodin, Adderall, Ritalin, or Xanax) without a doctor’s prescription
one or more times during their life.
†W > H > B
National Youth Risk Behavior Survey, 2009
www.cdc.gov/yrbs/
Percentage of High School Students Who Used a Condom During Last
Sexual Intercourse,* 1991 – 2009†
100
Percent
80
60
52.8
54.4
56.8
1993
1995
1997
58.0
57.9
1999
2001
63.0
62.8
61.5
61.1
2003
2005
2007
2009
46.2
40
20
0
1991
* Among students who had sexual intercourse with at least one person during the 3 months before the survey.
† Increased 1991–2003, no change 2003–2009, p < 0.05.
National Youth Risk Behavior Surveys, 1991–2009 www.cdc.gov/yrbs/
Youth Risk Behavior Survey
questions about mood…
“The next 5 questions ask about sad feelings and attempted suicide.
Sometimes people feel so depressed about the future that they may
consider attempting suicide, that is, taking some action to end their own
life. “
24. During the past 12 months, did you ever feel so sad or hopeless almost every day for two weeks or
more in a row that you stopped doing some usual activities?
25. During the past 12 months, did you ever seriously consider attempting suicide?
26. During the past 12 months, did you make a plan about how you would attempt suicide?
27. During the past 12 months, how many times did you actually attempt suicide?
A. 0 times B. 1 time C. 2 or 3 times D. 4 or 5 times E. 6 or more times
28. If you attempted suicide during the past 12 months, did any attempt result in an injury, poisoning,
or overdose that had to be treated by a doctor or nurse?
www.cdc.gov/yrbs/
Percentage of High School Students Who Felt Sad or
Hopeless,* 1999 – 2009†
100
Percent
80
60
40
28.3
28.3
28.6
28.5
28.5
26.1
1999
2001
2003
2005
2007
2009
20
0
* Almost every day for 2 or more weeks in a row so that they stopped doing some usual activities during the 12
months before the survey.
† No change 1999–2007, decreased 2007-2009, p < 0.05
National Youth Risk Behavior Surveys, 1999–2009 www.cdc.gov/yrbs/
Percentage of High School Students Who Made a Plan About
How They Would Attempt Suicide,* 1991 – 2009†
100
Percent
80
60
40
18.6
19.0
20
17.7
15.7
14.5
14.8
16.5
1999
2001
2003
13.0
11.3
10.9
2005
2007
2009
0
1991
1993
1995
1997
* During the 12 months before the survey.
† Decreased 1991–2009, p < 0.05.
National Youth Risk Behavior Surveys, 1991–2009 www.cdc.gov/yrbs/
Percentage of High School Students Who Attempted
Suicide,*
1991 – 2009†
100
Percent
80
60
40
20
7.3
8.6
8.7
7.7
8.3
8.8
8.5
8.4
6.9
6.3
1991
1993
1995
1997
1999
2001
2003
2005
2007
2009
0
* One or more times during the 12 months before the survey.
† No change 1991–2001, decreased 1991–2009, p < 0.05.
National Youth Risk Behavior Surveys, 1991–2009 www.cdc.gov/yrbs/
SUICIDE…
1. A leading cause (2nd or 3rd) of death in adolescents:
2.
3.
12% of teen deaths are suicide
Suicidal ideation very common in
adolescents: 20% per year
4. Suicide attempts: YRBS says 6% per year…wow!
a. Attempts are much more common in females
b. Suicides are much more often completed in males
5. What do you say to a teen or any patient who reports suicidal feelings?
(next slide)
6. What are some major worries/ “red flags”?
7. Suicide attempts:
3 days (avg. period of contemplation for elders)
1 day
(avg. period of contemplation for a young adult)
Hours… (avg period of contemplation for a teen…especially males)
at the moment of despair/hopelessness…
(appreciate the near universality of at least transient wishes to “give up”)
After the “first rules of first aid” are followed :
(approaching “the scene” safely, surveying the “ABCs”-attending to acute medical risks – e.g. lethality variables, imminent
threats etc)
Remember that providing health care is about fostering a renewed sense of hope and efficacy)
-ask kids (and any of our patients) questions like…:
-where did they think they would go?
-did they imagine starting over?
-Who did they think about? Were they among the living?
An elder? A compadre?
-What kind of appeal to a “higher power” did they make?
-?What kind of appeal did the “higher power” make to them?
-Did anyone notice?
-At what point did they think they’d “turned the corner” (in either direction)
and decided to try to live/die?
-What tools came into view?
The buddy system: Who will you turn to? Who turns to you?
This list is certainly not meant to be a script or the only ways to approach this…we just want
our patients to have the chance to not feel so alone or that the health care world isn’t
strong and safe enough to give them a place to reflect.
18
16
14
12
10
8
6
4
29% decline
Total
Firearm
Suffocation
Poison
Other
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
2
0
1985
rate/100,000
Suicide Rate, 15-24 year-olds
From 1994-2003, the youth suicide rate dropped by about 29%, driven almost exclusively by a drop in firearm
suicide. Suffocation (hanging) suicides increased, poisonings declined in the late ‘80s but were flat in the late
90s/early 2000s, and all other methods showed no change.
Catherine Barber: Harvard Injury Control Research Center
Pediatric
Psychopharmacotherapy Evidence

Majority based on anecdotal reports and adult studies

Minimal literature examining combined therapies and polypharmacy

Limitations include small sample sizes, lack of controls, narrow
diagnostic inclusion criteria and short duration of treatment
 Most prescriptions for psychiatric indications in juveniles considered
off-label (non-FDA approved)
 NIH promoting large, cooperative, multisite trials to address these
concerns
It is more than just the pills
“Body” Influences Mind
σ Sleep hygiene
σ Activities change cortisol
& testosterone levels, etc
σ Fresh air and romping
around
σ Diet
“Mind” influences Body
ψ Biofeedback –yoga,sports
ψ Thoughts about actions
ψ The phone call from
grandma
ψ Songs
ψ Meal milieu
ψ Media images
ψ The meaning of the
medication to
ψ The
ψ The
ψ The
ψ The
youth
parents
teachers
peers
FDA APPROVED- Peds psych meds

Attention-deficit Hyperactivity
Disorder

– All amphetamine and
methylphenidate formulations
(≥6yo)
 Dexedrine IR (≥3yo)
– Atomoxetine
– Guanfacine ER
– Clonidine ER


Aggression
– Risperidone & Aripiprazole for
aggression associated with
autism

Major Depression
– Fluoxetine (≥8yo)
– Escitalopram (≥12yo)

Obsessive-Compulsive Disorder
–
–
–
–
Sertraline (≥6yo)
Fluoxetine (≥7yo)
Fluvoxamine (≥8yo)
Clomipramine (≥10yo)
–
–
–
–
–
Risperidone (≥10yo)
Aripiprazole (≥10yo)
Quetiapine (≥10yo)
Lithium (≥12yo)
Olanzapine (≥13yo) – acute
treatment only
Bipolar Disorder
Schizophrenia
–
–
–
–
Risperidone (≥13yo)
Aripiprazole (≥13yo)
Quetiapine (≥13yo)
Olanzapine (≥13yo)
Regarding the Cary/Storck
“Pediatric Psychopharm Charts”….
( a separate attachment from the lecture handout)
Dear Psychiaty Clerkship students,
These slides are meant as, hopefully, an enjoyable quick
reference for perusal for psychopharm agents that we use in
child psychiatry… not the level of detail that you are expected
to know for the clerkship.
I will include some slides from these charts during my
presentation then try to hypontize you so that you don’t
think that you should memorize them.
Please Email me if you have questions…
Mick
A kid drew this a few years
ago, probably could
reverse the labels
lots of times…
Epidemiology

Dramatic increase in prescriptions
over last 20 years

? Over-medication
 Potential for sudden death and
cardiovascular problems with
stimulants
? Over-diagnosis
? Enhanced appreciation

Since 2003, FDA has issued
separate warnings regarding
increased
 Suicidal Ideation:
 Antidepressants
 Atomoxetine
 Antiepileptics
 Metabolic Disease
 Atypical antipsychotics
Recent data has resulted in the
removal of FDA warnings:
 AAP no longer recommends routine
pre-treatment cardiograms

Washington State House Bill 1088
– DSHS required to monitor
psychotropic use in youth
Stimulants

Short Term Effectiveness of Stimulants for ADHD well documented
 Over 200 published Randomized Control Trials (RCT), including studies
with preschoolers and adults
 Methylphenidate best studied, followed by dextroamphetamine and mixed
amphetamine salts
 65 – 75 % response rate, compared to 5 – 30 % placebo response
 All stimulants equally effective
 Except methylphenidate more effective if comorbid autism
 FDA approval for ADHD
 Age 6 for all, age 3 for DEX
 FDA Black Box Warning for amphetamine salts due to cardiotoxicity  removed
 Extended-release preparations
 Transdermal methylphenidate
 D-threo methylphenidate
 Lisdexamfetamine
– (Meth)amphetamine meanings?
α – Adrenergic Agents for “Autonomic Reactivity”
-for kids who can’t “pull” their punches
-hypervigilance
-overarousal

α2 – Adrenergic Agonists: Several small RCTs show efficacy in ADHD Tx
 Clonidine/Guanfacine
 FDA recently approved long-acting guanfacine and clonidine for ADHD
 (…why not the short-acting…which have been available for years and
are much cheaper?... “marketing” not clinical issues…)

α1 – Adrenergic antagonist: primarily case report data…
 Prazosin
 PTSD nightmares
Uses for Selective Serotonin Re-Uptake Inhibitors in Youth










Depression
Dysthymia
Bipolar Depression
Generalized Anxiety
Separation Anxiety Disorder
Panic Disorder
Obsessive Compulsive Disorder
Post-Traumatic Stress Disorder
Autism Spectrum Disorders
Chronic Headaches or Pain
SSRIs for Depression

Response rates 40-70% and Placebo rates 30-60%



Fluoxetine: First studied, Most consistent positive results
Only FDA-approved medications for pediatric depression:

Fluoxetine ≥ 8yo

Escitalopram ≥ 12yo
FDA Black Box Warning: Increased suicidal ideation

Increased risk of suicidal ideation during the first few months of treatment



4% for active medication vs 2% for placebo
No increase in suicide attempt
Debatable - ?increased suicide attempts concurrent with reduction in SSRI
prescriptions
 FDA monitoring recommendations:
 All patients being treated with antidepressants for any indication should be monitored
appropriately and observed closely for clinical worsening, suicidality, and unusual
changes in behavior, especially during the initial few months of a course of drug therapy,
or at times of dose changes, either increases or decreases.
SSRIs for OCD
4
Positive RCT’s, including two multisite trials
–Fluvoxamine, Sertraline and Fluoxetine all found
effective
–All FDA-approved for Tx of pediatric OCD
Tricyclic Antidepressants
Imipramine, Amitriptyline, Nortriptyline, Clomipramine, Desipramine
the old guard….not used much now

Depression: 13 studies, > 300 subjects: none were superior to placebo (50 –
60 % placebo response rates)

ADHD: several positive RCT’s, although not as effective as stimulants

Enuresis: several positive RCT’s for Imipramine
OCD: 3 positive RCT’s for Clomipramine, 1 RCT found Clomipramine helpful for
repetitive behaviors in autism
 Best Indications: Impramine for enuresis, Clomipramine for OCD.
 Not FDA approved for Depression/Anxiety – but still can be an option

Understanding The Trials
Combination of pharmacotherapy and psychotherapy most effective
treatment for both moderate to severe depression and OCD
– Mild symptoms typically remit within 4-6wks with psychotherapy
alone

High placebo response rates
 Expect spontaneous remission when treating mild depression
 “Placebo” is not equivalent to “no treatment”

Limited long-term data

Bias in pharmaceutical industry sponsored studies
Treatment of Pediatric Anxiety
Walkup, et al. N Engl J Med. 2008 Dec 25;
359(26):2753-66.
Example of growing data on “combined”
therapies….
Treatment for Adolescents with Depression Study
TADS team. Am J Psychiatry 2009; 166:1141-1149
Mood Stabilizers

Lithium
– One RCT (Geller et al., 1998) found lithium improved bipolar mood
symptoms and substance abuse
– Two positive, one negative RCTs for Disruptive Behavior/Aggression
– Large Open Label Trial (Kafantaris et al., 2003) (n = 100) had a 63%
response rate in adolescents with Bipolar I Disorder
– Open trials of combination lithium plus other mood stabilizers or
antipsychotics support benefit (Kafantaris et al., 2001; Findling et al.,
2003, Pavuluri et al., 2004)

NICHD funded Multisite COLT Trial underway for youth with Bipolar I
Disorder (ages 7 – 17)

Lithium FDA approved for Bipolar (ages 12 years and older)
Anticonvulsants / Mood Stablizers







FDA warnings about suicidality
Valproate – weight gain/rash/lPCO disease/liver & heme SEs
 limited efficacy…maybe some benefit for borderline personality regulation
Lamotrigine
 Effective In Adult Studies of Bipolar Depression
 Open label study supports use in adolescents with bipolar depression (Chang et al.,
2006) worry about Stevens Johnson syndrome/rash
Oxcarbazepine
 Few Adult Studies Show Efficacy
 Negative Trial in Youth (Wagner et al. 2006)
Carbamazepine
 Adult Studies Not as Robust as for VPA
Topiramate
 Negative adult trials, …..cognitive blunting
 Inconclusive support for youth (Delbello et al, 2005)
Gabapentin
 Large Controlled Trial in Adults was negative
Antipsychotics

Atypical antipsychotics provide the largest profit to pharmaceutical
companies

Molindone vs. Olanzapine and Risperidone
 As effective
 Fewer metabolic side effects
 1/10th the cost
 No longer produced!
 Significant adverse effects associated with all atypical antipsychotics
 Youth more susceptible to metabolic adverse effects than adults
Atypical Antipsychotics
FDA indications for Pediatrics

Risperidone
 Irritability for children and adolescents with Autism
 Adolescents with Schizophrenia
 Adolescents with Bipolar Disorder

Aripiprazole
 Adolescents with Schizophrenia
 Adolescents with Bipolar Disorder
Peds Psychopharm Summary

We generally treat symptom clusters
that span a variety of domains of
functioning and presentations of
distress
Domains: Cultural and Social Expectations,
Social and Physical Environment, Identity,
Behavioral Norms, Emotional Norms,
Perceptions, Learning Systems
Symptom clusters: Thought Organization, Mood
Regulation, Attentional /Impulse Control
Capacity, Social Relatedness

Substantial Empirical Evidence
Currently Supports:
Combination of psychotherapy and
psychopharmacology
–
–
–
–
Stimulants for ADHD
SSRIs for Depression and OCD
Lithium for Bipolar Disorder
Antipsychotics for Psychosis
Some RCT evidence for:


Antipsychotics for aggression
associated with autism spectrum
disorders
Alpha-agonists for ADHD symptoms,
primarily as adjunctive
 Very little study of polypharmacy
interventions
AND polypharmacy increasingly
common
Psychotherapeutic Interventions

Existing Evidence Suggests Traditional Therapies Most Often Used are
Not Clearly Effective …but
– Dialectical Behavioral Therapy, Motivational Interviewing and Trama Focused –
Cognitive Behavioral Thearpy are coming along…

Four Meta-Analytic Studies of Psychotherapy Research
– > 300 studies, subjects 2 – 18 years of age
– “Behavioral” Therapies Generally Superior
 ?easier to measure study variables…more “reductionistic” study variables?
 How would you design a study?

Effective Therapies Available, But Generally Not Used “by the book” in
Clinical Settings
Cognitive-Behavioral Therapy




Depression
– At least 10 Positive RCTs for Depression in Children and
Adolescents
 Comparison arms included wait list controls and nondirective
supportive psychotherapy
Anxiety
– Individual and Family CBT approaches found useful for Separation
Anxiety and Generalized Anxiety Disorders
– Behavioral Strategies useful for Phobias
OCD
– some positive trials in kids, well established efficacy in adults
– more robust support for “combination therapies”
PTSD
– Positive Trials, includes youth exposed to maltreatment
– “Trauma-focused CBT” – strong momentum as Evidence-based
Treatment (EBT) for children..must customize…
Other Behavioral Strategies

Conduct/Disruptive Behavioral Disorders …
 Problem-Solving Training
 Anger Management
 Assertiveness Training

ADHD – specific interventions
– Inconsistent findings with strategies designed to improve self
control
– Not much data on “neurofeedback” (fun to think about though)…
– Contingency Management and Behavioral Interventions helpful
 Generally not as powerful effects as stimulants.
 Time Consuming, difficulty with compliance
 Don’t always generalize to other settings or beyond the
treatment
Rising stars in therapy for kids

Trauma focused-Cognitive Behavioral Therapy
– Sponsored locally by the Harborview Sexual Assault Center
– Customizable modules…core construct: boosting resilience through the “trauma
narrative”, helping families build safety zones

Motivational Interviewing:
– Mentoring child, adolescent and family forays through their “risk grids”
– Showing up, now, in a range of pediatric challenges including
 Diabetes co-management, toddler sleep cycles, breast-feeding challenges

Dialectical Behavioral Therapy:
– Individual and group components
 Modified to fit for early teens, kids with developmental disabilities …
– Distress tolerance strategies
– Mindful practice
TRAUMA-FOCUSED
COGNITIVE-BEHAVIORAL THERAPY



Manualized Individual, Parent, and Conjoint Therapy
Targets:
– Post-traumatic Stress Symptoms
 Depression, anxiety, and behaviors resultant from
PTS
Goals:
– Eliminate symptoms PTS
– Develop parenting comfort and skills confronting
child’s PTS symptoms
TF-CBT METHOD

P: Psychoeducation, Positive Parenting

R: Relaxation Techniques

A: Affective Expression and Modulation

C: Cognitive Coping and Processing

T: Trauma Narrative

I: In vivo Exposure

C: Conjoint Child-Parent Sessions

E: Enhancing Future Safety and Development
Parenting Training Programs

Oppositional/Conduct Disorder
Interventions Designed to enhance parenting effectiveness, decrease
coercion and improve parent-child interactions, including
– Behavioral Family Intervention (Patterson 1974)
– Videotaped Modeling Parent Training (Webster-Stratton 1994)

Parenting Interventions and Family Therapy also helpful for
– Anxiety Disorders
– Eating Disorders
– Early childhood parent-child challenges…
 Go see PCIT (Parent Child Interactive Therapy) if you can…
Multisystemic Therapy (MST)

Aggressive case management, Comprehensive Psychiatric services
and Targeted Family Interventions used to maintain youth in their
homes and community systems

MST has better outcomes (including reduced substance abuse) and
more cost-effective than
– Hospitalization
– Incarceration

However, effects may dissipate over 12 - 16 months (Henggeler et al.,
2003)
Psychotherapy In Children and Adolescents: Summary

Best Evidence for
– CBT for Depression, Anxiety, PTSD
– CBT/behavioral strategies for conduct problems
– Parent Training for preschool challenges and conduct problems
– MST for Conduct Problems

Despite the availability of these Interventions
– Most clinicians not systematically trained to use them
– Most psychotherapy done in community settings is supportive in
nature, and may not be so effective
DSM V (just issued …2013)

For the psychiatry clerkship, we hope you appreciate the
big picture of child diagnoses, peruse the diagnostic criteria
to have familiarity with how we conceptualize.

Note some changes from DSC IV to DSM V…
 ADHD now a “neurodevelopmental” disorder…not primarily
categorized as a “disruptive behavior” disorder
 Changing the age of onset developed in DSM-IV (from 7 to 12?)
 Fewer symptoms required for a diagnosis of adult ADHD
 PTSD was taken from the “Anxiety” disorders category and given it’s
own realm
 Autism category streamlined: Did away with “Aspergers”
 new “mood dysregulation” disorder (? Helps broaden the mood
disorder options)
The following slides, with some diagnostic criteria, are not
meant to be inclusive…just a sampling of some of the diagnostic
realms and angles we encounter in child psychiatry
ADHD Criteria: Inattention


Six or more of the following for >6 mos
(Must be maladaptive and inconsistent with developmental
level)
– careless with details
– can’t keep on task
– doesn’t seem to listen when spoken to
– doesn’t follow through with instructions
– difficulty organizing
– reluctant to put in effort for school or homework
– often loses things necessary for activities
– is easily distracted
– is forgetful
ADHD Criteria: Hyperactivity-impulsivity



Six or more of the following for >6 mos
– Must be maladaptive and inconsistent with developmental ( level)
Hyperactivity
– often fidgets with hands or feet or squirms in seat
– often climbs or runs about … or feels restless
– difficulty playing or engaging in leisure
– often leaves seat when expected to remain in seat
– often is “on the go” or acts as if “driven by a motor”
– often talks excessively
Impulsivity
– often blurts out answers before questions completely asked
– has difficulty awaiting turn
– often interrupts or intrudes on others
Bipolar Disorder


Most disruptive, irritable children do not have bipolar disorder
New category of bipolar spectrum “mood dysregulation disorder”
– Given that so few kids have full bipolar pictures…how will this “new” disorder fit?

Prevalence of Bipolar Disorder Debated
– Estimates range between 0.4% - 6%, depending on symptom
severity
– Best estimate adolescent prevalence similar to adult: 1%
– 0.3% - 0.5% adults with bipolar had symptom onset before
10yo
 Peak incidence between 15 – 30yo

Psychosis with mania, frequent mood switching, and comorbidity
with ADHD are common
Unclear how youth symptoms associated with adult course

Conduct /Oppositional Defiant Disorder
Oppositional Defiant Disorder: …for six months
– Negativistic, pain in the …
 Loses temper, argues
 Defies
 Deliberately annoys/easily annoyed
 Angry, resentful, spiteful
 Wonder about the family variables
 Conduct Disorder : 3 or more in the last 12 mos. of behaviors like
– Truancy, runaways
– Aggression to people animals
– Destruction of property
– Deceitfulness/theft
– Serious violations of rules (though it easier to “get this dx” than we
might wish…)
– Can occur as part of other diagnoses (see PTSD)
– We always have to wonder about the “function” of the behavior….

Trauma- and Stressor-Related Disorders
• Reactive Attachment
• related to extreme/insufficient care….
• significant impact on affiliation
• debate on how to constue this after age 5
• Posttraumatic Stress Disorder
• DSMV now has appreciation of special early
childhood features
• Re-experiencing phenomena (flashbacks,
nightmares) as with adults
• Avoidance and trust issues…
• Re-enactment issues can be very different from
adults…
• Look at play themes
• Conduct regulation
Psychosis in children and adolescents

Schizophrenia is much rarer than in adults

Hallucinations in pre-adolescents are often anxiety (including PTSD) phenomena
(until “proven” otherwise)

Brief psychotic disorders…can be related to
 Obsessionality/anxiety
 Post-traumatic stress disorder
 Organic varilables

Psychosis often occurs in bi-polar mania
…. and adolescent depression

Organic contributors
 Neurologic/endocrine
 Eating disorders
 Autistic spectrum struggles
 Severe and profound intellectual disabilities
Autism Spectrum Disorder
 now includes a wide range of functioning…including what used to be called
Aspergers Disorder…
Deficits in in social interaction and communication
Deficits in nonverbal communication skills
Failure to develop appropriate peer relationships
Lack of social understanding, interests, reciprocity
 Restricted repetitive and stereotyped patterns
of behavior
Preoccupation with idiosyncratic interests
Inflexible adherence to routines/rules
Stereotypic motor mannerisms
 can occur with or without intellectual or language impairments
 Severity:
Level 3 – requiring very substantial supports
Level 2 – requiring substantial supports
Level 3 – requiring support…
Jokes - by Ralph (age 12)
“Ralph” met criteria for Autistic Spectrum disorder…
(level 1 – high functioning) I think that one of these might be a joke….
WHY did the pig cross the road?
To have some bacon and eggs.
WHY did the boy throw the clock out the window?
Because it woke his parents up, and now he has consequences!
WHERE’S boogie world?
Its all up your nose!
WHAT’S black and white and red all over?
A newspaper that you spilled ketchup on!
Anorexia and Bulimia

Anorexia Nervosa
–
–
–
–
–
–
–
(the most life-endangering psychiatric
diagnosis)
Restriction in energy intake
Intense fear of gaining wt
Disturbance in way body wt is
experienced
10:1 female/male ratio
No longer a criterion regarding missed
menstrual cycles
severity based on BMI
…contemplate the role of “the
web” and social media
(con and pro)
Treatment approaches: meal
support, activity restriction,
monitor electrolytes, EKG

Bulimia Nervosa
– Bingeing
– Sense of loss of control
– At least once a wk for 3
mos.
– Self-evaluation is unduly
influenced by body
shape/weight
– Be mindful of frequency
of transient eating
problems
Resilience

What protects some kids?
– temperament (arousal patterns/mood template)
– cognitive profile
– birth order
– specific ties inside or outside the “family”
– locus of control, well played age-specific defenses
– finding someone at the right time
– luck at avoiding the poorly timed risk (the beer, the peer insult, the
shaming moment etc)
– what seems like resilience now may correlate with problems later…and
vice versa
You’re the doctor…
1.
Build alliances (with permission, check in with, or at least wonder about,
home/family, peers, primary doc, school staff, coaches, chaplain, etc)
2. Your job is to help boost your patient’s adaptation and self-efficacy.
3. Ask “What is going well for you ?” and “What are you/they worried about?”
4. Help the kid look at their matrix of supports/influences.
5. Assess patient’s risk management skills, use your motivational interviewing
techniques. Be the “consultant”. Get the kid to be the lead investigator.
6. Maintain alliance (availability for check ins, track attributions, follow strengths)
7. Remember your own “serenity prayer”…
8. Savor the camaraderie and access to hopes and humanity.