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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: be familiar with the spectrum of psychiatric illness in the pediatric population and the assessment involved have a greater understanding of pediatric depression ADHD any others? Outline Starting Principles Spectrum of Psychiatric Disorders in the Pediatric Population Review of Pediatric Depression Review of ADHD Principles accurate diagnosis informs a comprehensive management plan biological, psychological, social contributors biological, psychological, social interventions medications used depending on diagnosis, symptoms, and severity antidepressants - SSRIs anti-anxiety - benzodiazepines anti-psychotics – atypical start low, go slow Spectrum of Psychiatric Disorders 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 2% children, 4-8% teens (: ♂ = 2:1) symptoms for 2 weeks: 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: suicide attempt - 9% of teens anxiety - phobias, separation anxiety behaviour - tantrums, oppositional, aggression somatic complaints psychosis – auditory hallucinations range in severity Depression continued … contributing factors (B/P/S) biological – ie genetics, history of depression psychological – ie loss, trauma, separation social – ie interpersonal, SES, academic comorbidity: anxiety, substance use, behaviour, etc prognosis: recurrence 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 interview with family interview with child/teen interview with parents collaterol information from school etc as required Depression continued … Differential Diagnosis – extensive 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 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 start low, go slow; increase as tolerated & as required Controversy 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): ie BZDs, atypical antipsychotics Depression continued … Red Flags 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 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: 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 5-9 % of children; ♂: = 4:1 (NB: under-Dx) symptoms – 2+ settings, onset < age 7 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 subtypes: 1) inattentive, 2) hyperactivity – impulsivity, 3) combined reference: DSM-IV ADHD continued etiology - DA mediated; problems with inhibitory & executive control factors: comorbidity 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 65% adulthood ADHD continued Assessment: Interview with Questionnaires family child / teen parents ie Connors Rating Scale – parent / teacher form Information from school Psychoeducational testing ADHD continued Differential Diagnosis – extensive 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 School Intervention (+) reinforcement, structure classroom modifications, individual education plan (IEP) Resources / References websites: www.adrn.org http://www.aacap.org/ (Facts for Families) ADHD continued Medications stimulants - 1st line short acting – Ritalin, Dexedrine long acting – ie Concerta, Dexedrine SR Blinded placebo / stimulant trials 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 requesting script renewals non-compliance substance abuse stockpiling medications medical problems - epilepsy ADHD continued Approach controversy “over-diagnosed” concerns about long-term side effects problems if no treatment academic, social, family comorbidity advise them to direct their questions / concerns MD Questions / Cases