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Assessment/Treatment of Aggression in Youth Copyright © The REACH Institute. All rights reserved. UAMS Disclosure Policy It is the policy of the University of Arkansas for Medical Sciences (UAMS) College of Medicine to ensure balance, independence, objectivity, and scientific rigor in all provided or jointly provided educational activities. All individuals who are in a position to control the content of the educational activity (course/activity directors, planning committee members, staff, teachers, or authors of CME) must disclose all relevant financial relationships they have with any commercial interest(s) as well as the nature of the relationship. Financial relationships of the individual’s spouse or partner must also be disclosed, if the nature of the relationship could influence the objectivity of the individual in a position to control the content of the CME. The ACCME describes relevant financial relationships as those in any amount occurring within the past 12 months that create a conflict of interest. Individuals who refuse to disclose will be disqualified from participation in the development, management, presentation, or evaluation of the CME activity. Copyright © The REACH Institute. All rights reserved. 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 Copyright © The REACH Institute. All rights reserved. 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 Copyright © The REACH Institute. All rights reserved. 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 Copyright © The REACH Institute. All rights reserved. Case Presentation: Your Patient Todd Copyright © The REACH Institute. All rights reserved. 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) Copyright © The REACH Institute. All rights reserved. SOAP Case Presentation: Todd continued • What would you do? • Audience input • See Todd’s scored Vanderbilt (L 1.2& 1.3) in Workbook Copyright © The REACH Institute. All rights reserved. NICHQ Vanderbilt Assessment Scale: Copyright © The REACH Institute. All rights reserved. Parent information Copyright © The REACH Institute. All rights reserved. NICHQ Vanderbilt Assessment Scale: Copyright © The REACH Institute. All rights reserved. Parent information Copyright © The REACH Institute. All rights reserved. Assessment of Aggression Copyright © The REACH Institute. All rights reserved. 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 Copyright © The REACH Institute. All rights reserved. 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” Copyright © The REACH Institute. All rights reserved. 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 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 Managing Aggressive Youth Question 1: True or False? “Your first step is to make a valid DSM diagnosis” Copyright © The REACH Institute. All rights reserved. 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 Copyright © The REACH Institute. All rights reserved. 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 Copyright © The REACH Institute. All rights reserved. Managing Aggressive Youth Question 2: True or False ? Response to treatment can be adequately monitored by using clinical interview and clinical judgment alone. Copyright © The REACH Institute. All rights reserved. False! T-MAY Recommendations • Define target symptoms & behaviors in partnership with parents and child • Assess target symptoms, treatment effects and outcomes with standardized measures Copyright © The REACH Institute. All rights reserved. Standardized Measures Useful For Aggression Include: • Vanderbilt • Modified Overt Aggression Scale (MOAS) • Nisonger Child Behavior Rating Form (N-CBRF) Copyright © The REACH Institute. All rights reserved. L2.9 Copyright © The REACH Institute. All rights reserved. L3.2 Copyright © The REACH Institute. All rights reserved. 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 Copyright © The REACH Institute. All rights reserved. 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 Copyright © The REACH Institute. All rights reserved. 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 Copyright © The REACH Institute. All rights reserved. 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 Copyright © The REACH Institute. All rights reserved. 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 Copyright © The REACH Institute. All rights reserved. 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. Copyright © The REACH Institute. All rights reserved. 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. Copyright © The REACH Institute. All rights reserved. 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. Copyright © The REACH Institute. All rights reserved. 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 Copyright © The REACH Institute. All rights reserved. Table Activity Debrief • MOAS Scores • Behavior management? • Which atypical, what dose? • What rating scale? Copyright © The REACH Institute. All rights reserved. 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! Copyright © The REACH Institute. All rights reserved. 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 Copyright © The REACH Institute. All rights reserved. REMINDER: Please fill out Unit L evaluation Copyright © The REACH Institute. All rights reserved. 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 Copyright © The REACH Institute. All rights reserved. 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 Copyright © The REACH Institute. All rights reserved. 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 Copyright © The REACH Institute. All rights reserved. 8