Download 11-Psych Course 462_Child Psychiatry for Medical Students_17

Child Psychiatry for
Medical Students Part I
Khalid Bazaid, MB BS, FRCPC
Assistant Professor
Child & Adolescent Psychiatrist
Department of Psychiatry
College of Medicine
King Saud University
5/24/2017
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Outlines

Introduction to Child & Adolescent psychiatry

Review disorders first usually diagnosed in Infancy, Childhood and
Adolescence
– MR
– PDD
– ADHD
– Disruptive Disorders

Review childhood presentation of general psychiatric disorders
– Elimination disorders
– Mood
– Anxiety
– Psychosis
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Remember: Children are not miniature adults
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5 Days
2 Months
1 Year
28 Years
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Child Psychiatry
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Relatively small specialty numerically BUT has a large reach.
Between general psychiatry and pediatrics
7-20% children have mental health problems
10% of these see specialist child mental health services
40% of consultations in GP are family ones
> 25% of these relate to mental health
Therefore 10% of total GP consultations may be children’s mental
health related
 Pediatric OPD 30% mental health related
 Pediatric inpatients nearer 60%.
 An appreciation of child mental health is important whatever specialty
you go into.
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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
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Distribution of Disorders
Diagnostic groupings:
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Disruptive behaviour disorders – Conduct disorder (prevalence 5.3%),
Oppositional defiant disorder
Hyperkinetic disorders (ADHD) (up to 5%).
Tic Disorders e.g. Tourettes’ (up to 2%)
Affective disorders – Depression (2%), BPAD.
Anxiety disorders (3.8%), GAD, phobias, separation anxiety, panic, PTSD.
Obsessive Compulsive disorder (3%)
Dissociative and somatoform disorders (rare)
Psychosis e.g. drug induced, schizophrenia (v. rare in childhood, peak
incidence late teens to early twenties).
Developmental disorders – general (2.4%) or specific learning disability,
autistic spectrum disorders (0.06 to 1.5%) and other PDD
Social functioning disorders e.g. elective mutism, attachment disorders
Eating disorders (3%) e.g. Anorexia, Bulimia, Binge eating
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EVALUATION STRATEGIES
Patient Interview
Testing
Collateral Information
(Parents, School)
(IQ, Education, Projective,
Personality, Neuropsychiatry,
labs, EEG, MRI)
Observation
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Mental Retardation
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Epidemiology: 1-3% in US
IQ 70 or less on an individually
administered IQ test
Onset before age 18
Delays in two or more adaptive areas,
e.g., self care; communication; work;
leisure; health; or safety
Testing:
•
Intelligence testing - compares
individual test performance to
normative of age group
• E.g., WISC-IV (6 to17y) or
Stanford-Binet V5 (2 to 85+y)
•
Vineland Adaptive Behavior
Scales -measure of personal and
social skills
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Mental Retardation
(~ 85%)
(~ 10%)
(~ 3%)
(~
1-2%)
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Treatment Considerations
•
Family is coping with loss of “ideal” child:
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•
Grief and loss issues
Appropriate placement and support:
School setting, day care, group homes, sheltered workshop
and relief care
•
Specific problems responsive to medications:
e.g. seizures; depression; hyperactivity ; aggression
•
May experience “independent” psychiatric disorders:
e.g. schizophrenia, bipolar disorder, etc.
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Pervasive Developmental Disorders
Disorders with severe and pervasive impairment in essential
developmental areas:
 Reciprocal social skills
 Language development
 Range of behavioral repertoire
DSM-IV includes the following under PDD:
1. Autism
2. Rett’s Disorder
3. Childhood Disintegrative Disorder
4. Asperger’s Disorder
5. PDD, not otherwise specified
Language Disorders: Autism and Other Pervasive Developmental Disorders, Pediatr Clin N Am 54 (2007) 469–481
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Autism Spectrum Disorders (ASD)
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ASD are increasingly common neurodevelopment disorder
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Characterized by functional impairments in a triad of symptoms:
(1) limited reciprocal social interactions
(2) disordered verbal and nonverbal communication
(3) restricted, repetitive behaviors or circumscribed interests
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These behaviors can vary in severity from mild to disabling
IQ: At least half of all children who have autism have mental
retardation
Autism appears in early childhood, often as young as age 2 or 3
Prevalence rate for all ASD 0.6% (Am J Psychiatry 2005; 162(6): 1133-41)
Up to 25% have grand-mal seizures and about 50% non-specific EEG
abnormalities
boys to girls 4:1
Asperger’s disorder 10:1 as many boys to girls
Genetic / environment
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Epidemiology of Autism
• Prevalence rate of Autism Spectrum Disorders is
about 1%
• Up to 25% have grand-mal seizures and about 50%
non-specific EEG abnormalities
• 50 to 70% have some degree of MR
• Boys are effected 3 to 5 times more often than girls
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Etiology of Autism
• Psychological theories have not been confirmed:
Not caused by “refrigerator mother” or bad parenting
• Heritability over 90%
• Association with a variety of disorders:
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Congenital rubella & Postnatal infection
Genetic disorders, including Fragile X
Metabolic disorders
Tic disorders
OCD
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Asperger’s Disorder
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“High functioning autism”
No delays in language and cognitive development
Stereotypic, repetitive mannerisms
Lack of interactive play/communication
Impaired communication skills
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PDD NOS
When there is no severe and pervasive
impairment in the development of reciprocal
social interaction, or communication skills, or
when stereotyped behaviors and activities are
present, but the criteria are not met for a
specific pervasive developmental disorder.
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Interventions in PDD/Autism
Presently:
No curative treatment; early detection and symptomatic
approaches
Mainstay:
Structured behavioral and educational programs; speech and
language services
Medication:
To control seizures, hyperactivity, SIB, severe aggression, or
mood disorders
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Externalizing Disorders in Children
(ADHD, CD, ODD)
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Attention Deficit/Hyperactivity Disorder
(ADHD)
• Present before age 7
• Persist for at least 6 months and be more frequent and severe
than is typical for children at comparable developmental stages
• Symptoms in two or more settings
• Boys to girls 3 : 1
• DSM-IV-TR distinguishes ADD WITH & WITHOUT
hyperactivity, and recognizes a predominantly hyperactive
subtype
• Persists in some patients into adolescence and Adulthood
• Normal IQ
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INATTENTION
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no attention to details
difficulty focusing
not listening
easily distracted
forgetful not
following through
difficulty organizing
avoids effortful tasks
loses things
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HYPERACTIVITY
IMPULSIVITY
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fidgets
leaves seat
runs/climbs
loud
on the go
excessive talk
blurts
can't wait turn
interrupts/butts in
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Academic
limitations
Relationships
Occupational/
vocational
Legal
difficulties
Low self
esteem
ADHD
Motor vehicle
accidents
Injuries
Smoking and
substance abuse
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ADHD Diagnosis
•
ADHD is more difficult to reliably diagnose in early childhood
(age 4-6)
•
Obtain developmental and medical history
•
Get standardized questionnaires from parents and teachers
•
Observation in clinic setting may or may not show symptoms
described by parents
•
Psycho-educational testing useful if LD suspected
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‫اسم الطفل ‪:‬‬
‫‪........................................‬‬
‫رقم المستشفى ‪:‬‬
‫‪.............................‬‬
‫العمر ‪:‬‬
‫‪................‬‬
‫التعليمات‪:‬‬
‫الرجاء وضع دائرة حول الرقم الذي يناسب وصف الطفل أمام كل واحده من العبارات التالية‪:‬‬
‫أبدا ً‬
‫قليلً‬
‫كثيرا ً‬
‫كثيرا ً جدا ً‬
‫( ‪)1‬‬
‫غالبا ً ما يتململ أو يتحرك في مقعده ‪.‬‬
‫‪0‬‬
‫‪1‬‬
‫‪2‬‬
‫‪3‬‬
‫( ‪)2‬‬
‫يجد صعوبة في البقاء جالسا ً ‪.‬‬
‫‪0‬‬
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‫من السهل تشتيت انتباهه ‪.‬‬
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‫‪1‬‬
‫‪2‬‬
‫‪3‬‬
‫( ‪)4‬‬
‫يجد صعوبة في انتظار دوره وسط أقرانه ‪.‬‬
‫‪0‬‬
‫‪1‬‬
‫‪2‬‬
‫‪3‬‬
‫( ‪)5‬‬
‫غالبا ً ما يندفع في االجابة على األسئلة دون تفكير ‪.‬‬
‫‪0‬‬
‫‪1‬‬
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‫تسلسل‬
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‫وصف الطفل‬
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‫( ‪)6‬‬
‫يجد صعوبة في اتباع التعليمات ‪.‬‬
‫‪0‬‬
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‫‪3‬‬
‫( ‪)7‬‬
‫يجد صعوبة في حصر انتباهه فيما يطلب منه عمله ‪.‬‬
‫‪0‬‬
‫‪1‬‬
‫‪2‬‬
‫‪3‬‬
‫( ‪)8‬‬
‫غالبا ً ما ينتقل من نشاط قبل إكماله ‪ ،‬إلى نشاط آخر ‪.‬‬
‫‪0‬‬
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‫‪2‬‬
‫‪3‬‬
‫( ‪)9‬‬
‫يجد صعوبة في اللعب بهدوء ‪.‬‬
‫‪0‬‬
‫‪1‬‬
‫‪2‬‬
‫‪3‬‬
‫(‪)10‬‬
‫غالباًَ ما يتكلم بافراط ‪.‬‬
‫‪0‬‬
‫‪1‬‬
‫‪2‬‬
‫‪3‬‬
‫(‪)11‬‬
‫غالبا ً ما يقاطع اآلخرين يقحم نفسه عليهم ‪.‬‬
‫‪0‬‬
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‫‪3‬‬
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‫غالبا ً ما يبدو عليه عدم اإلنصات ‪.‬‬
‫‪0‬‬
‫‪1‬‬
‫‪2‬‬
‫‪3‬‬
‫(‪)13‬‬
‫غالبا ً ما يضيع أشياءه الخاصة(األدوات المدرسية مثلً)‬
‫‪0‬‬
‫‪1‬‬
‫‪2‬‬
‫‪3‬‬
‫(‪)14‬‬
‫غالبا ً ما يقوم بأعمال خطرة بدنيا ً دون اكتراث لما ينتج عن‬
‫ذلك ‪.‬‬
‫‪0‬‬
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Neuroanatomical
Neurochemical
ADHD
Environmental
Genetic
Etiology
CNS
insult
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NIMH Press Release November 12, 2007
Brain Matures a Few Years Late in ADHD,
But Follows Normal Pattern
http://www.nimh.nih.gov/science-news/2007/brain-matures-a-few-years-late-inadhd-but-follows-normal-pattern.shtml
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Treatment
Behavioural
Therapy
Medication
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ADHD
Child
Home
School
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ADHD Treatment
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•
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Psychoeducation essential; medication alone is usually not
sufficient for the treatment of ADHD
Parent training in behavioral management and schoolbased behavioral interventions
FDA approved medications include stimulants and
Atomoxetine
 Note: Stimulant medications improve attention in
normal individuals as well as children with ADHD
Establish communication with teachers/school; potentially
includes accommodations and IEP
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The CONCERTA® Formulation
Laser-Drilled
Hole
MPH
Compartment
#1
MPH
Overcoat
MPH
Compartment
#2
Tablet
Shell
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Push
Compartment
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ADHD Outcomes
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ADHD can be a lifetime disorder, with nearly 2/3 of children
continuing with symptoms as adults
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Learning disabilities frequently comorbid in children with
ADHD and not responsive to medications
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Adult outcome studies show more relationship problems,
lower educational and professional achievement, more traffic
violations and higher health care costs for cohort members
with ADHD compared to unaffected controls

Long term outcome strongly influenced by comorbid ODD,
CD, and substance abuse
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Conduct /Oppositional Defiant Disorder
 ODD: …for six months
– Negativistic
 Loses temper, argues
 Defies
 Deliberately annoys/easily annoyed
 Angry, resentful, spiteful
 CD: 3 or more in the last 12 mos.
–
–
–
–
Aggression to people animals
Destruction of property
Deceitfulness/theft
Serious violations of rules
Toilet training
 Begins 18-30 months
 Most children control urination by day at 2.5 years and at
night by 3.5-4 years
 Factors that effect refusal include:
 early training
 excess parent-child conflict
 constipation
 Prerequisites:
 bowel and bladder regularity
 sphincter control
 psychological ability to delay
 desire to please adults
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Enuresis
 Primary vs Secondary Enuresis
 Nocturnal vs. Diurnal
 DIURNAL enuresis after
continence is achieved should
prompt evaluation
 Family history of enuresis
 Laboratory studies are unlikely to
be positive unless other clinical
findings are present
 Treatment with medications and
behavioral plan
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Selective Mutism

Failure to speak in specific
social situations despite
speaking in other
situations
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Classified as an anxiety
disorder
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High association with
depression
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SUICIDE…
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A leading cause (2nd or 3rd) of death in adolescents:

12% of teen deaths are suicide

Suicidal ideation very common in adolescents: 20% per
year

Suicide attempts: 10% per year
a. More common in females
b. More often completed in males

What do you say to a teen who reports suicidal feelings?

What are some major worries/ “red flags”?
Treatment Modalities
 Individual Therapies (play, behavioral,
cognitive, supportive, dynamic)
 Family Therapy & Parent Training
 Group Therapy - especially important for
adolescents
 Medication therapy
 Can be use alone or in combination
 Outpatient or inpatient
Evidence Based Treatments in Child and
Adolescent Psychiatry
McClellan and Werry, JAACAP, 2003;42:1388-1400
Psychopharmacology:
 Most medication practices for psychiatric illnesses in youth
based on anecdotal reports and/or adult literature
 Essentially no literature examining combined therapies and
polypharmacy
 Limitations include small sample sizes, lack of controls, narrow
diagnostic inclusion criteria and/or 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
Pediatric Psychopharmacology
 Increased Public Concern
– Questions of over-medication and over-diagnosis
 Since 2003, FDA has issued separate warnings regarding
– Antidepressants (suicidality)
– Atypical antipsychotics (metabolic problems)
– Stimulants (potential for sudden death and cardiovascular
problems)
– Atomoxetine (suicidality)
– Antiepileptics (suicidality)
 Washington State passed a law requiring DSHS to establish a
monitoring system for psychotropic agents in youth (House Bill
1088)
Stimulant Medications
 Short Term Effectiveness of Stimulants for ADHD
well documented
> 160 published RCT, including studies with preschoolers
and adults
– 65 – 75 % response rate, compared to 5 – 30 % placebo
response
– Most Trials 12 weeks or less
– Methylphenidate best studied, followed by
dextroamphetamine, pemoline and mixed amphetamine
salts (Concerta, Adderall, Metadate, etc)
– FDA approved for ADHD (age 6 for MPH, age 3 for DEX)
… now FDA “Black Box” warning for amphetamine salts:
cardiotoxicity
Selective Serotonin Re-Uptake Inhibitors
 Sampling of the data…
 Fluoxetine
– Emslie et al., 1997: Fluoxetine (n = 96)
 Moderate to severe depression,
 58% vs 33% placebo response.
– Emslie et al., 2002: Fluoxetine (n = 219),
 Significant improvement, but 53% placebo response rate
– Simeon et al., 1990. Fluoxetine (n = 40 adolescents)
 No difference, both groups had ~ 66% response rate
 Fluoxetine FDA approved for Depression in Youth (the only
medication approved for depression in kids)
Selective Serotonin Re-Uptake Inhibitors:
other indications
 OCD/Anxiety:
–4 Positive RCT’s, including two multisite trials
–Fluvoxamine, Sertraline and Fluoxetine studied
 All three agents: FDA approved for OCD in youth
Tricyclic Antidepressants
Imipramine, Amitriptyline, Nortriptyline, Clomipramine, Desipramine
the old guard….
 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 indicated for Depression/Anxiety
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
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 effective as stimulants.
 Time Consuming, difficulty with compliance
 Don’t always generalize to other settings or beyond the
treatment
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
 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 Trained to Use Them
– Most Psychotherapy done in Community Settings is
supportive in nature, and may not be effective
Questions after lecture?
 Please e-mail ([email protected]) or call
(01 467 1717)
 Interested in learning more about child and
adolescent psychiatry?
– Arrange to attend OPD
– Consider an elective rotation during internship
or otherwise
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