Download Pediatric Psychiatry

PHM 456H
Introduction to Pediatric Pharmacy Practice 2004
Drug Related Issues in
Pediatric Psychiatry
Claire De Souza BSc MD FRCP(C)
November 4th 2004
Audience Survey:
Experience with pediatric psychiatry:
medications?
patients?
Learning Objectives
At the end of this presentation, the student will:
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be familiar with the spectrum of psychiatric illness in
the pediatric population and the assessment involved
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have a greater understanding of
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pediatric depression
ADHD
any others?
Outline
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Starting Principles
Spectrum of Psychiatric Disorders in the
Pediatric Population
Review of Pediatric Depression
Review of ADHD
Principles
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accurate diagnosis
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informs a comprehensive management plan
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biological, psychological, social contributors
biological, psychological, social interventions
medications used depending on diagnosis, symptoms,
and severity
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antidepressants - SSRIs
anti-anxiety - benzodiazepines
anti-psychotics – atypical
start low, go slow
Spectrum of Psychiatric Disorders
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Mood Disorders
Anxiety Disorders
Psychotic Disorders
Substance Use Disorders
Personality Disorders
Disruptive Behavioural Disorders
Elimination Disorders
Eating Disorders
Tic Disorders
Somatoform Disorders
etc.
Reference: DSM-IV
Depression
Depression
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2% children, 4-8% teens (: ♂ = 2:1)
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symptoms for 2 weeks:
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mood – “bored”, irritable
cognitive – SI, guilt, worthlessness, concentration
physical - change in sleep↑, appetite↑, energy, psychomotor
interpersonal – change in interest level
change in functioning (social, academic) / xs distress
other features:
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suicide attempt - 9% of teens
anxiety - phobias, separation anxiety
behaviour - tantrums, oppositional, aggression
somatic complaints
psychosis – auditory hallucinations
range in severity
Depression continued …
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contributing factors (B/P/S)
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biological – ie genetics, history of depression
psychological – ie loss, trauma, separation
social – ie interpersonal, SES, academic
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comorbidity: anxiety, substance use, behaviour, etc
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prognosis: recurrence
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20-60 % recurrence in 2 yrs; 70% within 5 yrs
episodes become more frequent, more severe, last longer
20-40%  bipolar disorder within 5 years
Depression continued …
Assessment
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interview with family
interview with child/teen
interview with parents
collaterol information from school etc as required
Depression continued …
Differential Diagnosis – extensive
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Adjustment Disorder, Dysthymic Disorder, Bipolar
Disorder, Anxiety Disorder, Eating Disorder,
Psychotic Disorder, Disruptive Behavioural
Disorder, Personality Disorder, Substance use
Disorder, General Medical Condition (thyroid,
anemia, mono etc), Bereavement etc.
Depression continued …
Management (B / P / S):
 Psychoeducation
 Medications
 Therapy – individual (CBT, IPT), family
 School Intervention
 Resources / References
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websites:
http://www.mooddisorders.on.ca/mdao.asp
http://www.aacap.org/ (Facts for Families)
Depression continued …
Medications
 duration: 9 months or more
 1st line: SSRIs (ie Prozac, Zoloft, Celexa) – off-label
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start low, go slow; increase as tolerated & as required
Controversy
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
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Efficacy – limited evidence - Prozac
Safety – Health Canada warning
 MD to monitor: SI, disinhibition, agitation, akathisia
off-label use based on limited studies, experience, adult studies
drug interactions – cytP450
Medications added as required (Sx, Rx resistance):
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ie BZDs, atypical antipsychotics
Depression continued …
Red Flags
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requesting script renewals
appearing dysphoric, suicidal,
hypomanic, psychotic
non-compliance: withdrawal,
worsening symptoms
stockpiling medications, buying
++OTCs
medical problems – cytP450
drug interactions
Depression continued …
Approach
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review Health Canada warning
discuss need for monitoring by MD
advise them not to stop medication suddenly
questions / concerns  MD
advise them about what to look for:
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ie. restlessness, disinhibition, aggression,
anxiety, worsened depression
direct them to resources
if concerned about patient’s safety – refer to ER
Reference: FDA website, Health Canada, NIMH websites
Attention Deficit
Hyperactivity Disorder
ADHD
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5-9 % of children; ♂:  = 4:1 (NB: under-Dx)
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symptoms – 2+ settings, onset < age 7
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inattention – careless mistakes, can’t sustain attn, distractible, forgetful,
disorganized, loses things, doesn’t listen, doesn’t complete tasks, avoids
time/effort-consuming tasks
hyperactivity – fidgets, leaves seat, ↑ runs/climbs, on the “go”, xs
talking, can’t play quietly
impulsivity- blurts out, interrupts, problems waiting turn
interferes with functioning: academic, family, social
diagnosis
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subtypes: 1) inattentive, 2) hyperactivity – impulsivity, 3) combined
reference: DSM-IV
ADHD continued
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etiology - DA mediated; problems with inhibitory &
executive control
factors:
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comorbidity
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biological – FHx, difficult temperament
psychological - self-esteem
social - interpersonal, academic, poor social skills
learning disorders (in 40% with ADHD), behavioural
problems (ODD, CD), substance abuse, depression, anxiety
prognosis
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65%  adulthood
ADHD continued
Assessment:
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Interview with
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Questionnaires
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family
child / teen
parents
ie Connors Rating Scale – parent / teacher form
Information from school
Psychoeducational testing
ADHD continued
Differential Diagnosis – extensive
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Learning disorder
General Medical Condition (hearing, vision,
thyroid, congenital, genetic, lead poisoning, head
injury etc)
Adjustment Disorder, Dysthymic Disorder, Bipolar
Disorder, Anxiety Disorder, Psychotic Disorder,
Disruptive Behavioural Disorder, Personality
Disorder, Substance use Disorder, etc.
ADHD continued
Management (B / P / S):
 Psychoeducation
 Medications
 Social skills training
 Parent management
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School Intervention
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(+) reinforcement, structure
classroom modifications, individual education plan (IEP)
Resources / References
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websites: www.adrn.org
http://www.aacap.org/ (Facts for Families)
ADHD continued
Medications
 stimulants - 1st line
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short acting – Ritalin, Dexedrine
long acting – ie Concerta, Dexedrine SR
Blinded placebo / stimulant trials
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to determine dose, acceptability
coordinated with objective scale – ie Connors Rating Scale
restricted use – limited scripts
abuse potential
other medications for co-morbidity – ie depression, anxiety,
tics
Use – for school day primarily; also, during weekend &
summer if problems (social, academic) off meds
ADHD continued
Red Flags
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requesting script renewals
non-compliance
substance abuse
stockpiling medications
medical problems - epilepsy
ADHD continued
Approach
 controversy
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“over-diagnosed”
concerns about long-term side effects
problems if no treatment
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academic, social, family
comorbidity
advise them to direct their questions / concerns 
MD
Questions / Cases