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Download 11-Psych Course 462_Child Psychiatry for Medical Students_17
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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 1 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 5/24/2017 2 Remember: Children are not miniature adults 5/24/2017 3 5 Days 2 Months 1 Year 28 Years 5/24/2017 4 Child Psychiatry 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. 5/24/2017 5 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 5/24/2017 7 Distribution of Disorders Diagnostic groupings: 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 5/24/2017 8 EVALUATION STRATEGIES Patient Interview Testing Collateral Information (Parents, School) (IQ, Education, Projective, Personality, Neuropsychiatry, labs, EEG, MRI) Observation 5/24/2017 9 Mental Retardation • • • • • 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 5/24/2017 10 5/24/2017 11 Mental Retardation (~ 85%) (~ 10%) (~ 3%) (~ 1-2%) 5/24/2017 12 Treatment Considerations • Family is coping with loss of “ideal” child: • 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. 5/24/2017 13 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 5/24/2017 14 Autism Spectrum Disorders (ASD) ASD are increasingly common neurodevelopment disorder 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 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 5/24/2017 15 5/24/2017 16 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 5/24/2017 17 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: 5/24/2017 Congenital rubella & Postnatal infection Genetic disorders, including Fragile X Metabolic disorders Tic disorders OCD 18 Asperger’s Disorder • • • • • “High functioning autism” No delays in language and cognitive development Stereotypic, repetitive mannerisms Lack of interactive play/communication Impaired communication skills 5/24/2017 19 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. 5/24/2017 20 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 5/24/2017 21 Externalizing Disorders in Children (ADHD, CD, ODD) 5/24/2017 22 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 5/24/2017 23 INATTENTION no attention to details difficulty focusing not listening easily distracted forgetful not following through difficulty organizing avoids effortful tasks loses things 5/24/2017 HYPERACTIVITY IMPULSIVITY fidgets leaves seat runs/climbs loud on the go excessive talk blurts can't wait turn interrupts/butts in 24 Academic limitations Relationships Occupational/ vocational Legal difficulties Low self esteem ADHD Motor vehicle accidents Injuries Smoking and substance abuse 5/24/2017 25 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 5/24/2017 26 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 1 2 3 ( )3 من السهل تشتيت انتباهه . 0 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 2 3 تسلسل 27 وصف الطفل 5/24/2017 28 ( )6 يجد صعوبة في اتباع التعليمات . 0 1 2 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 1 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 1 2 3 ()12 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 1 2 3 5/24/2017 Neuroanatomical Neurochemical ADHD Environmental Genetic Etiology CNS insult 5/24/2017 29 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 5/24/2017 30 Treatment Behavioural Therapy Medication 5/24/2017 ADHD Child Home School 31 ADHD Treatment • • • • 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 5/24/2017 32 The CONCERTA® Formulation Laser-Drilled Hole MPH Compartment #1 MPH Overcoat MPH Compartment #2 Tablet Shell 5/24/2017 Push Compartment 33 5/24/2017 34 ADHD Outcomes ADHD can be a lifetime disorder, with nearly 2/3 of children continuing with symptoms as adults Learning disabilities frequently comorbid in children with ADHD and not responsive to medications 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 5/24/2017 35 5/24/2017 36 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 5/24/2017 38 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 5/24/2017 39 Selective Mutism Failure to speak in specific social situations despite speaking in other situations Classified as an anxiety disorder High association with depression 5/24/2017 40 SUICIDE… 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 5/24/2017 56